DIAGNOSTIC AND THERAPEUTIC MANAGEMENT OF CEREBRAL VASOSPASM AFTER SAH
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1 DIAGNOSTIC AND THERAPEUTIC MANAGEMENT OF CEREBRAL VASOSPASM AFTER SAH Erich Schmutzhard Department of Neurology, NICU Medical University Hospital A-6020 Innsbruck, Austria
2 Neurologie Intensiv Universitätskliniken Innsbruck Complications of SAH Vasospasm and DCI Definition and Epidemiology Transitory arterial vasoconstriction, which is seen 72 hours or later after the hemorrhage with a maximum around day 7 it lasts usually no more than 15 (rarely 20) days 50 75% of angiographies: narrowing of th lumen "Delayed cerebral ischemia" (DCI) "Delayed ischemic neurological deficit" (DIND) This vasoconstriction manifests clinically only in ca % Not all patients develop a vasospasm (complex pathophysiology) DCI causes in 25% permanent neurological sequelae or, even, death
3 Complications of SAH Vasospasm and DCI Pathophysiology Delayed and reversible vasculopathy Disturbance of regualatoy mechanisms of the vasculature-tone (Imbalance of endogenous vasodilatators and endogenous vasoconstrictors) Liberation of "spasmogenic" substances when subarachnoidal blood is lysing Impaired capacity of autoregulation (CBF-reduction) Hypovolemia (reduction of regional CPP) (Local) activation of coagulation cascade leading to formation of microthrombi Lackner et al, 2010 Neurologie Intensiv Universitätskliniken Innsbruck
4 Neurologie Intensiv Universitätskliniken Innsbruck Complications of SAH Vasospasm and DCI Diagnostic procedures in awake patients: clinical - neurological exam Technical diagnostic means in patients with impaired consciousness or when analgosedated cerebral panangio CT-, MR-Angiography (incl. Perfusion-CT/MR) Neurosonography (TCD) increased mean bloodflow velocity (v mean > 120 cm/s) increase of v mean 50% MCA/ICA (LINDEGAARD)-Index > 3 further monitoring methods cerebral microdialysis, ptio2, PET
5 Neurologie Intensiv Universitätskliniken Innsbruck Complications of SAH Vasospasm and DCI possibilities of intervention Perfusion pressure controlled (permissive) hypertension Ppr Q = 4 8Lh Radius/Diameter prophylaxis/ therapy of vasoconstriction Viscosity Hemodilution cerebral bloodflow neuroprotection"
6 Neurologie Intensiv Universitätskliniken Innsbruck Complications of SAH Vasospasm and DCI Prophylaxis of Vasospasm Efficacy Reduction/ Cleaning of subarachnoid blood/hematoma mechanically (e.g. rinsing during surgery)? pharmacologically? fenestration of the lamina terminalis, lumbar drainage? Modulation of inflammatory mechanisms Theory Inactivation / blockade of spasmogenic substances free radical scavengers, anti-oxydants (+)/ iron chelating agents? Endothelin-receptor antagonists +++ Blockade of constriction of muscles of the blood vessels (Systemic) Calcium-channel blocking agents (+) (Local) "prolonged-release" polymers ++
7 Cerebral Vasospasm Therapeutic possibilities Efficacy Transluminal Balloon-Angioplasty +++ Technical limitations, only possible in large-diameter vessel portions (ICA, M1, BA, VA, A1) Ausgangsbefund Intervention Befund nach PTA In ca. 90% prolonged effect rapid re-constriction seen in ca. 10% thromboembolic events (ca. 5%) und rupture of the vessel (!!) as substantial complications therefore abandoned Neurologie Intensiv Universitätskliniken Innsbruck
8 Neurologie Intensiv Universitätskliniken Innsbruck Cerebral Vasospasm Therapeutic possibilities Efficacy Intra-arterial pharmacologic Vasodilatation (as bolus) +++ temporary effect various agents with different mode of actions, e.g. Papaverin, Nimodopin (i.a.pressure pump delivery over 24 h persisting effect), Verapamil, Milrinon, Fasudil Optimisation of cerebral hemodynamics (HHH-therapy) (+) Therapeutic Hypothermia targeted temp. management?
9 Neurologie Intensiv Universitätskliniken Innsbruck Cerebral Vasospasm Therapeutic possibilities The reality in a Neurocritical care Unit Hypervolemia Hemodilution Permissive Hypertension Increase of Ischemia-tolerance
10 Cerebral Vasospasm Therapeutic possibilities General therapeutic management Admission to (N)ICU with advanced systemic and cerebral (neuro-) monitoring Maintenance and reestablishment of appropriate oxygenation, perfusion and metabolic Homoiostasis Prevention of hypovolemia, fever, hypo- and hyperglycemia and electrolyte derangements Prophylaxis and therapy of infections Prophylactic administration of the calcium channel blocker Nimodipin (Nimotop ) Recent studies prove the equal efficacy of oral (5 6mal 60 mg/d) and intravenous application (continuous1 2 mg/h). HOWEVER: CAVE malabsorption Cave: hypotensive effect of nimodipine sufficient MAP/CPP is essential continuous administration of Magnesium normal Mg-level! Cave: Hypotension!! Neurologie Intensiv Universitätskliniken Innsbruck
11 Neurologie Intensiv Universitätskliniken Innsbruck Cerebral Vasospasm Therapeutic possibilities HHH-Therapy (therapeutic Hypertension, Hypervolemia und Hemodilution) H(HH) in patients with neurologic (focal) signs and symptoms or newly developed cerebral infarction (cct) =(DCI) due to vasospasm generous administration of volume together with vasopressors (e.g. noradrenalin, phenylephrin) and inotropic agents (e.g.dobutamine) Hemodilution (questionable efficacy) colloidal infusions (e.g.hes) rate of complications: ca % volume overload, pulmonary edema, cardiac insufficiency, derangement of coagulation and electrolytes advanced cardiac, hemodynamic and pulmonary MONITORING essential and obligatory, in particular in patients at risk
12 Cerebral Vasospasm New therapeutic possibilities Endothelin-Receptor-Antagonists CONSCIOUS-2 (C2)(Clipping) and CONSCIOUS-3 (C3)(Coiling) mid 2010: C2 completed, End 2010: C3 prematurely terminated Moddified acc to Macdonald RL et al., Stroke 2008;39: Neurologie Intensiv Universitätskliniken Innsbruck
13 Cerebral Vasospasm New therapeutic possibilities Erythropoietin Erythropoetin alpha (e.g. Erypo ) i.v U in 30 min for 3 consecutive days (total dosage U) Modifiziert nach Tseng MY et al., J Neurosurg 2009;111: Neurologie Intensiv Universitätskliniken Innsbruck
14 Cerebral Vasospasm New therapeutic possibilities Statins Simvastatin p.o. 40 mg/d or Pravastatin p.o. 40 mg/d Modified acc. Chou SH et al., Stroke 2008;39: Neurologie Intensiv Universitätskliniken Innsbruck
15 Cerebral Vasospasm New therapeutic possibilities Nicardipin "prolonged-release" Implantate NPRIs (10 Implants à 4 mg Nicardipin) Modified acc. To Barth M et al., Stroke 2007;38: Neurologie Intensiv Universitätskliniken Innsbruck
16 Neurologie Intensiv Universitätskliniken Innsbruck Cerebral Vasospasm New therapeutic possibilities From: Schmutzhard, Beer, Vajkoczy, 2010) MAP!!! Awake patient: clinical-neurological exam!!!
17 Neurologie Intensiv Universitätskliniken Innsbruck Complications of SAH Vasospasm and DCI (DCI) DIND: is it only narrowing of the Lumen- (= Vasospasm )?
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32 Neuro-ICU Innsbruck Thank you for your attention and many thanks to my coworkers: Bettina Pfausler, Ronny Beer, Raimund Helbok, Greghor Broessner, Peter Lackner, Marlene Fischer, Anelia Dietmann, Alois Schiefecker
33 Neuro-ICU Innsbruck Thank you for your attention and many thanks to my coworkers: Bettina Pfausler, Ronny Beer, Raimund Helbok, Gregor Broessner, Peter Lackner, Stephanie Klien, Marlene Fischer, Anelia Dietmann, Alois Schiefecker
Neurointensive Care of Aneurysmal Subarachnoid Hemorrhage. Alejandro A. Rabinstein Department of Neurology Mayo Clinic, Rochester, USA
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