Symptomatic Vasospasm Research Articles

Cerebral vasospasm after selective amygdalohippocampectomy.

Symptomatic cerebral vasospasm (CV) is a frequently observed complication after aneurysmal subarachnoid haemorrhage (SAH).[1] Infrequently, it is known to occur after skull base surgeries and surgeries for medically intractable epilepsy (viz., temporal lobectomy and selective amygdalo-hippocampectomy (AHE).[2] Factors predicting the occurrence of CV after AHE have been described.[3] Transcranial Doppler (TCD) has been suggested as an invaluable modality for the detection of CV after epilepsy surgery.[3] We report a case of AHE where the patient developed symptoms of CV even in the absence of predictive factors and normal TCD findings.

Developments in Neurovascular Diseases and Treatments

Vascular diseases of the cerebral circulation represent a complex and diverse spectrum of pathology. Within the cerebrovascular field, there have been numerous recent advances in patient diagnosis, evaluation, imaging analysis, medical therapies, microsurgical treatments, and minimally invasive therapeutic modalities. These improvements have been driven by research developments from in vitro, in vivo, translational, and clinical studies. We review and add to the primary literature concerning this special issue. Stroke is a major cause of morbidity and mortality. Although intravenous tissue plasminogen activator has been a validated medical therapy in patients with acute ischemic stroke, there are many patients who fail to meet the defined time window for treatment. Neuroprotective agents for acute stroke could provide a major therapeutic advantage for many patients. In this issue, H.-K. Liew et al. demonstrate that “Granulocyte-Colony Stimulating Factor Increases Cerebral Blood Flow via a NO Surge Mediated by Akt/eNOS Pathway to Reduce Ischemic Injury.” Further studies are indicated to better define potential alternative medical therapies in acute ischemic stroke patients. Although earlier randomized clinical trials (RCTs) challenged the use of endovascular therapy in acute cerebrovascular occlusion [1–3], refinements in patient selection and three recent RCTs have validated the benefit of endovascular mechanical thrombectomy, preferably with retrievable stents (i.e., stentrievers), in patients with large vessel occlusion [4, 5]. Limitations of prior RCTs of endovascular stroke intervention included the use of earlier generation thrombectomy devices. In this issue, O. Ozdemir et al. provide us with “Predictors of a Good Outcome after Endovascular Stroke Treatment with Stent Retrievers”. Long-term follow-up in the International Study of Unruptured Intracranial Aneurysms (ISUIA) [6] and the International Subarachnoid Hemorrhage Aneurysm Trial (ISAT) has validated both microsurgical clipping and endovascular coiling in the treatment of ruptured and unruptured aneurysms [7]. As these outcomes are based on patients who were primarily treated during the 1990s, they may be based on antiquated means of patient evaluation and treatment. Recently, there have been many advances in medical therapies, imaging, microsurgical treatment, and endovascular therapies for cerebral aneurysms [8]. In the current issue, N. Ajiboye et al. provide us with an update on “Unruptured Cerebral Aneurysms: Evaluation and Management.” Cerebral vasospasm continues to be a leading cause of morbidity and mortality following aneurysm rupture. Recent RCTs have not provided us with further therapeutic strategies [9]. Perhaps refinements in patient evaluation and selection will improve patient outcomes. S. H. Sheen et al. provide a protocol on “Intravenous Flat-Detector Computed Tomography Angiography for Symptomatic Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage.” These new imaging modalities may yield a less invasive means for the evaluation and treatment of patients with aneurysmal subarachnoid hemorrhage. Recent RCTs and prospective cohort studies have challenged current management strategies for unruptured cerebral arteriovenous malformations (AVMs), but these analyses have not been without limitations [10, 11]. When indicated, current AVM interventions include microsurgery, radiosurgery, and embolization. These therapeutic options are also often used individually or as part of a multimodality approach. In this issue N. Ajiboye et al. provide us with an update through “Cerebral Arteriovenous Malformations: Evaluation and Management.” Additionally, S. Peschillo et al. provide us with a review on treatment options in “Brain AVMs: An Endovascular, Surgical, and Radiosurgical Update.” Neurovascular diseases are a heterogeneous group of disorders that are often associated with poor clinical outcomes. S. Tabuchi provides us with a review on “Auditory Dysfunction in Patients with Cerebrovascular Disease” and A. Y. Lu et al. provide us with an assessment of “Hemifacial Spasm and Neurovascular Compression.” Although the majority of neurovascular diseases are primarily arterial pathologies, cerebral venous diseases may also incur significant morbidity. To round out this issue, we provide an update and review of “Endovascular Treatment of Venous Sinus Stenosis in Idiopathic Intracranial Hypertension: Complications, Neurological Outcomes, and Radiographic Results.” Although cerebrospinal fluid diversion has been a mainstay of treatment in patients with idiopathic intracranial hypertension (IIH) refractory to medical therapy, recent advances in endovascular therapies have provided an effective alternative treatment option. Specifically, venous sinus stenting has been shown to provide durable neurological improvement in IIH patients with venous sinus stenosis and a significant physiologic pressure gradient. Further studies regarding associated complications, neurological outcomes, and radiographic results are necessary. Improvements in clinical evaluation, imaging, and treatment will lead to better outcomes in patients with neurovascular disease. Although there continue to be many advances in neurovascular disease, these options must be carefully assessed and compared to existing modalities to ascertain the best practices for our patients. Within this compilation of studies, we hope to elucidate areas of uncertainty, recent developments, and clinical necessity. Robert M. Starke Stephen J. Monteith Andrew M. Southerland R. Webster Crowley Nohra Chalouhi Dale Ding David M. Hasan Aaron S. Dumont

Intraventricular Hemorrhage Is Associated with Early Hydrocephalus, Symptomatic Vasospasm, and Poor Outcome in Aneurysmal Subarachnoid Hemorrhage

We hypothesized that the subset of patients with early hydrocephalus following aneurysmal subarachnoid hemorrhage may represent a subset of patients with a more vehement inflammatory reaction to blood products in the subarachnoid space. We thus examined risk factors for early hydrocephalus and examined the relationship between early hydrocephalus and symptomatic vasospasm as well as clinical outcome. We retrospectively analyzed all patients presenting to our institution with subarachnoid hemorrhage over a 7-year period. We examined for risk factors, including early hydrocephalus, for poor clinical outcome and symptomatic vasospasm. We found intraventricular hemorrhage to be strongly associated with the development of early hydrocephalus. In univariate analysis, early hydrocephalus was strongly associated with both poor functional outcome and symptomatic vasospasm. In multivariate analysis, intraventricular hemorrhage and tobacco use were associated with symptomatic vasospasm; intraventricular hemorrhage, intraparenchymal hemorrhage, and symptomatic vasospasm were associated with poor functional outcome. We found that intraventricular hemorrhage was strongly associated with early hydrocephalus. Further exploration of the mechanistic explanation is needed, but we suggest this may be from a combination of obstruction of cerebrospinal fluid pathways by blood products and inflammation in the choroid plexus resulting in increased cerebrospinal fluid production. Further, we suggest that both early hydrocephalus and cerebral vasospasm may be parts of the overall inflammatory cascade that occurs with intraventricular hemorrhage and ultimately results in a poorer clinical outcome.

Pituitary necrosis and vasospasm following removal of craniopharyngioma

Abstract We report a case of vasospasm complicating delayed pituitary necrosis after craniopharyngioma resection in an 18-year old female. This is the first reported case that utilizes aggressive blood pressure management, fluid optimization, and rheologic doses of mannitol to successfully treat severe symptomatic vasospasm.

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage.

Case fatality rates after aneurysmal subarachnoid hemorrhage (aSAH) have decreased over time, and many patients treated with modern paradigms return to a normal life. However, there is little information on predictors of excellent functional outcome after aSAH. In this study, the authors investigated predictors of excellent outcome in a modern consecutive series of patients with aSAH. A retrospective review was conducted of patients with aSAH admitted between 2001 and 2013. The primary outcome measure was excellent functional outcome, defined as modified Rankin Scale (mRS) score of 0 or 1 at last follow-up within 1 year of aSAH. Three hundred seventy-three patients were identified with posthospital follow-up. Excellent outcome was noted in 236 patients (63.3%), including an mRS score of 0 in 122 (32.7%) and an mRS score of 1 in 114 (30.6%). On univariate analysis, the following factors were associated with an excellent outcome: indicators of less severe bleeding, such as better World Federation of Neurosurgical Societies grade at any of the times of assessment, better modified Fisher grade, and absence of intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and symptomatic hydrocephalus; aneurysm treatment with coil embolization; absence of symptomatic vasospasm, delayed cerebral ischemia, and radiological infarction; absence of in-hospital seizures; lack of need for CSF diversion; fewer hours with fever; less severe anemia; and absence of transfusion. On multivariable analysis, the 4 variables that were most strongly associated with excellent outcome were presence of good clinical grade after neurological resuscitation, absence of ICH on initial CT scan, blood transfusion during the hospitalization, and radiological infarctions on final brain imaging. Excellent outcomes (mRS score 0-1) can be achieved in the majority of patients with aSAH. The likelihood of excellent outcome is predicted by good clinical condition after resuscitation, absence of ICH on presentation, no evidence of infarction on brain imaging, and absence of blood transfusion during hospitalization.

Transfer Time to a High-volume Center for Patients with Subarachnoid Hemorrhage Does Not Affect Outcomes

The objective of our study was to examine patients with aneurysmal subarachnoid hemorrhage transferred and directly admitted to our institution in order to determine how transfer time affects outcomes. A retrospective cohort study was performed of all patients undergoing treatment for aneurysmal subarachnoid hemorrhage between 2005 and 2012 at the University of Michigan. Variables, including transfer time, were tested for their independent association with the primary outcomes of symptomatic vasospasm and 12-month outcome as well as secondary outcomes of aneurysm rebleeding and 12-month mortality. During the study period, 263 (87.4%) patients were transferred to our institution and 38 (12.6%) were directly admitted for treatment of aneurysmal subarachnoid hemorrhage. Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. Higher Hunt-Hess grade was associated with the occurrence of symptomatic vasospasm as well as with poorer 12-month outcome. Transfer time was not associated with the occurrence of symptomatic vasospasm, 12-month outcome, rebleeding, or 12-month mortality. We believe our data argue that protocols should emphasize early resuscitation and stabilization followed by safe transfer rather than a hyperacute transfer paradigm. However, transfer time should be minimized as much as possible so as not to delay time to definitive treatment.

The relationship between ruptured aneurysm location, subarachnoid hemorrhage clot thickness, and incidence of radiographic or symptomatic vasospasm in patients enrolled in a prospective randomized controlled trial

The relationship between ruptured aneurysm location, subarachnoid hemorrhage clot thickness, and incidence of radiographic or symptomatic vasospasm in patients enrolled in a prospective randomized controlled trial

Changes in cerebral blood flow velocity in supine and sitting position in patients with aneurysmal subarachnoid hemorrhage

Early mobilization in intensive care units (ICU) provides respiratory, neurological and cardiovascular benefits in hospitalized patients. However, the orthostatic effects of changing from a supine to a sitting position may interfere with cerebral hemodynamics of patients with aneurysmal subarachnoid hemorrhage (aSAH). To describe the changes in mean cerebral blood flow velocity (MCBFV) in supine and sitting position, in adult patients with aSAH, with asymptomatic vasospasm (AVS) or without vasospasm (VS) at a neurosurgical ICU. Descriptive case series study in 21 patients with aSAH, both with and without VS. They were positioned in a supine 30° position and then seated at the edge of bed for six minutes. MCBFV was measured by transcranial Doppler (TCD), and hemodynamic variables in both positions were registered. After this basal assessment and for 21 days after the episode of SAH, patients were seated once a day and signs of VS were recorded. No significant changes in MCBFV or hemodynamic variables were detected during position changes, except for an increase in heart rate in the sitting position. No patient with AVS at the onset, had symptomatic VS during the 21 days of follow up when patients were seated. Among patients with a normal MCBFV at baseline, five patients (24%) had VS at a mean of three days after the first time that they were seated on the edge of bed. Sitting patients at the edge of the bed is a safe mobilization alternative for patients who suffered aSAH who did not have VS or had AVS.

Effectiveness of intraarterial administration of fasudil hydrochloride for preventing symptomatic vasospasm after subarachnoid hemorrhage.

We examined the effect of intraarterial administration of fasudil hydrochloride (IAFC), a Rho kinase inhibitor, for the prevention of symptomatic vasospasm after SAH by evaluating cerebral circulation. We evaluated IAFC cases of 57 sides of 38 patients (12 men and 26 women, average age 60.2 years old) diagnosed with aneurysmal subarachnoid hemorrhage (SAH) from February 2012 to November 2012. All cases were treated by clipping or coil embolization within 48 h after onset. Indication for IAFC was the existence of a spastic change on follow-up digital subtraction angiography (DSA) compared with that of onset. Clipping was performed in 30 cases and coil embolization in 8 cases. IAFC was performed an average of 6.6 days after onset. Color gradient mapping demonstrated reduction of the circulation time after IAFC compared with before IAFC on 39 sides, no change on 15 sides, and extension on 3 sides. Average arterial circulation time before IAFC was 2.25 ± 0.57 s and after IAFC was 1.95 ± 0.55 s. IAFC significantly shortened average arterial circulation (P = 0.005). No case developed symptomatic vasospasm after IAFC. IAFC significantly reduced the cerebral circulation time after aneurysmal SAH and might be effective for the prevention of symptomatic vasospasm.

Clot-clearance rate in the sylvian cistern is associated with the severity of cerebral vasospasm after subarachnoid hemorrhage.

Rapid clot removal and clearance has been proposed as an effective tool for preventing cerebral vasospasm after subarachnoid hemorrhage (SAH). We examined the relationship between clot-clearance rate and the severity of cerebral vasospasm in 110 consecutive patients with aneurysmal SAH. We measured clot-clearance rates per day in the basal and Sylvian cisterns, and evaluated the presence of symptomatic vasospasm based on changes in clinical symptoms and the appearance of a new low-density area on a computed tomography (CT) scan. The severity of symptomatic cerebral vasospasm was associated with age and the SAH grade on admission; however, we observed no significant difference between these variables in patients with urokinase irrigation or fasudil hydrochloride treatment. The mean clot-clearance rates per day for patients with asymptomatic and permanent delayed ischemic neurological deficit were 41.9 and 41.5 %, respectively, in the basal cistern (P = 0.7358) and 37.7 and 23.9 %, respectively, in the Sylvian cistern (P = 0.0021). The reduced clot-clearance rate in the Sylvian cistern increased the risk of vasospasm-related infarction (P = 0.0093) and markedly reduced unfavorable outcomes (P = 0.0115).

Prophylactic intra-arterial administration of fasudil hydrochloride for vasospasm following subarachnoid haemorrhage.

We evaluated patients treated with prophylactic intra-arterial administration of fasudil hydrochloride (IAF) after subarachnoid haemorrhage (SAH). Between August 1998 and December 2012, 92 patients with aneurysmal SAH were treated with IAF for angiographic vasospasm without ischemic symptoms after their follow-up angiography. Patients comprised 50 women and 42 men, aged 24-83 (mean 56.6) years. IAF consisted of 15 mg of fasudil hydrochloride dissolved in 20 ml physiological saline and injected through a catheter during approximately 15 min, after diagnostic angiography. The clinical outcome was evaluated using the Glasgow Outcome Scale (GOS) at discharge and ischemic lesions resulting from vasospasm were assessed on computed tomography (CT) scan at discharge. Forty-eight patients underwent surgical clipping and 44 patients underwent endovascular coiling. Angiographic improvement was observed in all patients (100 %). At discharge, 76 (83.0 %) of 92 patients showed good recovery on GOS. Nine patients developed progression of delayed ischemic neurological deficits (DIND) and three of these patients had ischemic lesions on CT scans. No patient had any significant changes in vital signs or any other adverse effects resulting from IAF. IAF therapy was safe and effective for patients with vasospasm following SAH. Prophylactic IAF therapy may prevent symptomatic vasospasm.

Double cisterna magna blood injection model of experimental subarachnoid hemorrhage in dogs.

Several animal subarachnoid hemorrhage (SAH) models have been proposed to study the etiology and treatment for cerebral vasospasm. We describe the experimental procedures of a canine double-hemorrhage model of SAH and discuss the pathophysiological parameters and occurrence of angiographic delayed cerebral vasospasm using magnetic resonance (MR) imaging and digital subtraction angiography. Autologous blood was injected twice on days 1 and 3 into the cerebellomedullary cistern of 36 female beagles. All animals showed delayed angiographic vasospasm in the vertebrobasilar arteries on day 7. The degree of vasospasm was 29-42% of the arterial diameter. However, this model showed no symptomatic vasospasm or ischemic changes detected by MR imaging. This animal model can produce reproducible delayed vasospasm without detectable cerebral infarction on MR imaging. This model allows evaluation of the effect of treatment on delayed vasospasm in the same animals. The canine double-hemorrhage model of SAH is suitable for the quantitative and chronological study of delayed angiographic vasospasm, but not for investigating early brain injury and delayed cerebral ischemia.

Endovascular management of cerebral vasospasm.

Cerebral vasospasm remains a feared complication from subarachnoid hemorrhage. Vasospasm typically occurs from three to fourteen days post-aneurysm rupture, with peak risk on Day 7. Up to 50% of patients with angiographic vasospasm will subsequently develop delayed cerebral ischemia; 15-20% of this subset will develop stroke or death despite maximal medical therapy. We define symptomatic vasospasm as the presence of neurological worsening after exclusion of other identifiable causes, such as seizure, hydrocephalus, intracerebral hemorrhage, or metabolic dysfunction. This video demonstrates the set-up and treatment protocol for endovascular intervention of symptomatic vasospasm not responsive to maximal medical management. The video can be found here: http://youtu.be/q7YvxLzIDnU .

Milrinone Via Lumbar Subarachnoid Catheter for Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Delayed ischemic neurological deficit (DIND) due to symptomatic vasospasm is a major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to elucidate the safety and feasibility of intrathecal milrinone infusion via lumber subarachnoid catheter for prevention of DIND after aSAH. We diagnosed 425 consecutive patients with aSAH who received clipping or coil embolization within 48h after arrival. Patients with the evidence of vasospasm on CT angiography (CTA) received the milrinone therapy via lumbar subarachnoid catheter. DIND, delayed cerebral infarction (DCI), and modified Rankin scale at 3months after SAH were used for the assessment of outcome. Of 425 patients, 170 patients (40.0%) with CTA-proven vasospasm received the milrinone therapy. DIND was observed in 68 patients (16.0%), DCI in 30 patients (7.1%), and the overall mortality was 7.2%. In patients with WFNS grade IV and V aSAH, 26 out of 145 patients (17.9%) were presented with DIND, 12 (8.3%) with DCI, and the mortality was 16.0%. No major complication related to the milrinone injection was observed. Intrathecal milrinone injection via lumbar catheter was safe and feasible, and further randomized prospective studies are needed to confirm the effectiveness of this regimen in the patients with SAH.

Monitoring of Cerebral Blood Flow and Metabolism Bedside in Patients with Subarachnoid Hemorrhage – A Xenon-CT and Microdialysis Study

Cerebral ischemia is the leading cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Although 70% of the patients show angiographic vasospasm only 30% develop symptomatic vasospasm defined as delayed cerebral ischemia (DCI). Early detection and management of reversible ischemia is of critical importance in patients with SAH. Using a bedside Xenon enhanced computerized tomography (Xenon-CT) scanner makes it possible to measure quantitative regional Cerebral blood flow (CBF) bedside in the neurointensive care setting and intracerebral microdialysis (MD) is a method that offers the possibility to monitor the metabolic state of the brain continuously. Here, we present results from nine SAH patients with both MD monitoring and bedside Xenon-CT measurements. CBF measurements were performed within the first 72 h following bleeding. Six out of nine patients developed DCI at a later stage. Five out of six patients who developed DCI had initial global CBF below 26 ml/100 g/min whereas one had 53 ml/100 g/min. The three patients who did not develop clinical vasospasm all had initial global CBF above 27 ml/100 g/min. High lactate/pyruvate (L/P) ratio was associated with lower CBF values in the area surrounding the catheter. Five out of nine patients had L/P ratio ≥25 and four of these patients had CBF ≤ 22 ml/100 g/min. These preliminary results suggest that patients with initially low global CBF on Xenon-CT may be more likely to develop DCI. Initially low global CBF was accompanied with metabolic disturbances determined by the MD. Most importantly, pathological findings on the Xenon-CT and MD could be observed before any clinical signs of DCI. Combining bedside Xenon-CT and MD was found to be useful and feasible. Further studies are needed to evaluate if DCI can be detected before any other signs of DCI to prevent progress to infarction.

Low neurologic intensive care unit hemoglobin as a predictor for intra-arterial vasospasm therapy and poor discharge modified Rankin Scale in aneurysmal subarachnoid haemorrhage-induced cerebral vasospasm

BackgroundIntra-arterial vasospasm therapy (IAVT) with vasodilators, balloon angioplasty, and cerebral blood flow augmentation devices are therapies for aneurysmal subarachnoid hemorrhage-induced symptomatic cerebral vasospasm refractory to maximal medical management. Our aim...

Preconditioning Effect on Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

Recent experimental evidence indicates that endogenous mechanisms against cerebral vasospasm can be induced via preconditioning. To determine whether these vascular protective mechanisms are also present in vivo in humans with aneurysmal subarachnoid hemorrhage. A multicenter retrospective cohort of patients with aneurysmal subarachnoid hemorrhage was examined for ischemic preconditioning stimulus: preexisting steno-occlusive cerebrovascular disease (CVD) and/or previous cerebral infarct. Generalized estimating equation models were performed to determine the effect of the preconditioning stimulus on the primary end points of radiographic vasospasm, symptomatic vasospasm, and vasospasm-related delayed cerebral infarction and the secondary end point of discharge modified Rankin Scale score. Of 1043 patients, 321 (31%) had preexisting CVD and 437 (42%) had radiographic vasospasm. Patients with preexisting CVD were less likely to develop radiographic vasospasm (odds ratio = 0.67; 95% confidence interval = 0.489-0.930; P = .02) but had no differences in other end points. In terms of the secondary end point, patients with preexisting CVD did not differ significantly from patients without preexisting CVD in mortality or unfavorable outcome in multivariate analyses, although patients with preexisting CVD were marginally more likely to die (P = .06). This retrospective case-control study suggests that endogenous protective mechanisms against cerebral vasospasm-a preconditioning effect-may exist in humans, although these results could be the effect of atherosclerosis or some combination of preconditioning and atherosclerosis. Additional studies investigating the potential of preconditioning in aneurysmal subarachnoid hemorrhage are warranted.

Norepinephrine as a potential aggravator of symptomatic cerebral vasospasm: two cases and argument for milrinone therapy.

Background. During hypertensive therapy for post-subarachnoid hemorrhage (SAH) symptomatic vasospasm, norepinephrine is commonly used to reach target blood pressures. Concerns over aggravation of vasospasm with norepinephrine exist. Objective. To describe norepinephrine temporally related deterioration in neurological examination of two post-SAH patients in vasospasm. Methods. We retrospectively reviewed two charts of patients with delayed cerebral ischemia (DCI) post-SAH who deteriorated with norepinephrine infusions. Results. We identified two patients with DCI post-SAH who deteriorated during hypertensive therapy with norepinephrine. The first, a 43-year-old male presented to hospital with DCI, failed MABP directed therapy with rapid deterioration in exam with high dose norepinephrine and MABP of 140–150 mm Hg. His exam improved on continuous milrinone and discontinuation of norepinephrine. The second, a 39-year-old female who developed DCI on postbleed day 8 responded to milrinone therapy upfront. During further deterioration and after angioplasty, norepinephrine was utilized to drive MABP to 130–140 mm Hg. Progressive deterioration in examination occurred after angioplasty as norepinephrine doses escalated. After discontinuation of norepinephrine and continuation of milrinone, function dramatically returned but not to baseline. Conclusions. The potential exists for worsening of DCI post-SAH with hypertensive therapy directed by norepinephrine. A potential role exists for vasodilation and inotropic directed therapy with milrinone in the setting of DCI post-SAH.

Risk Factors Associated with Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage

We studied the risk factors associated with cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). The subjects were 370 patients with ruptured aneurysms who fulfilled all of the following criteria: admission by day 2 after onset, operation performed by day 3 by the same surgeon (T.I.), Hunt-Hess grade I–IV, availability of bilateral carotid angiograms acquired by day 2 and repeated between days 7 and 9. The demographic, clinical, radiographic, surgical, laboratory, and electrocardiographic data were analyzed for angiographic vasospasm (AV), symptomatic vasospasm (SV), and cerebral infarction on computed tomography (CT) scan. Both CT-evident SAH and AV were graded as 0–IV. Among the 370 patients, AV grade III–IV, SV, and cerebral infarction occurred in 26%, 24%, and 20%, respectively. Univariate analysis showed that Hunt-Hess grade III–IV, SAH grade III–IV, intracerebral or/and intraventricular hemorrhage, rebleeding, cigarette smoking, hypertension, alcohol intake, leukocytosis, hyperglycemia, and electrocardiographic QTc prolongation, left ventricular hypertrophy (LVH), and ST depression were significantly related to at least one of AV grade III–IV, SV, or cerebral infarction. Multivariate analysis showed that SAH grade III–IV was the most important risk factor for vasospasm followed by LVH on electrocardiogram, cigarette smoking, and hypertension. AV grade III– IV, SV, and cerebral infarction occurred in 57%, 54%, and 39% of the 46 smokers with LVH, and in 43%, 49%, and 35% of the 68 patients who had both LVH and hypertension, respectively. CT-evident SAH, LVH, cigarette smoking, and hypertension are associated with vasospasm. In smokers or hypertensive patients, premorbid LVH appears to predict much more severe vasospasm.

破裂動脈瘤に待機的に治療を行うリスク

The optimal timing of surgery for patients with subarachnoid hemorrhage (SAH) has been debated over the last few decades. Recent literature largely advocates “early surgery,” namely within 48 hours after the onset of bleeding, for ruptured cerebral aneurysms. However, early surgery is not always safe for some complicated aneurysms. It can be even hazardous due to the vulnerability of the brain during the acute stage of SAH. Although elective surgery may be a useful option for better surgical outcome for these high-risk aneurysms, the actual risk of postponing surgery in the modern neurosurgical environment has not been well understood. We retrospectively analyzed the surgical outcome of our patients with SAH between January 2008 and September 2012. Our management policy for SAH is to perform clipping within 48 hours after hospitalization. Among a total of 235 patients with SAH, however, we found 43 patients who were treated after 48 hours from admission for various reasons. We analyzed the characteristics of these aneurysms, reasons for waiting, complications due to awaiting surgery, and outcomes. Among these 43 patients, the mean waiting period was 11 days (2–69 days, median; 6 days). During this period, we had four cases (9.3%) of rebleeding and three of these four patients died due to rerupture. Other complications included severe pneumonia in three (7.0%), symptomatic vasospasm and hydrocephalus in two (4.7%), respectively. These complications were all successfully treated. The reasons for elective surgery included a tight operating room schedule (23.3%), severe systemic conditions of patients (14.0%), the necessity of high flow bypass (18.6%), the time required for arranging endovascular surgery (14.0%), and elective clipping for aneurysms located in the posterior circulation (4.7%). Symptomatic vasospasm before surgery was observed in two cases (4.7%). Good outcome (GR and MD on Glasgow Outcome Scale) was achieved in 65.2% of patients treated during 3–7 day and in 60.0% of patients treated after seven days or later. The mortality was 11.6%, including three patients with rebleeding. Although “early surgery” is critical to treat patients with aneurysmal SAH, it is also true that “timing of surgery” is not the only factor affecting the outcome. Our study indicated that elective surgery can be an important option for aneurysms with high surgical risks in the acute phase of SAH under relatively acceptable complication rates and can provide useful data when the elective surgery is carefully planned for those selected cases.