====== Cerebral Vasospasm Guidelines ======

see [[Hypervolemia for vasospasm]]
    
[[Induced hypertension for vasospasm]]
    
[[Nimodipine for vasospasm]]

[[Transcranial doppler for vasospasm diagnosis]]
   
[[Vasospasm diagnosis]]
----

In 2012, the [[American Heart Association]] and the [[American Stroke Association]] published updated [[evidence]]-based [[guideline]]s on the comprehensive [[management]] of [[aneurysmal subarachnoid hemorrhage]] (aSAH), including the management of [[cerebral vasospasm]] and [[delayed cerebral ischemia]] ([[DCI]]). 

These guidelines have been endorsed by the [[American Association of Neurological Surgeons]], the [[Congress of Neurological Surgeons]], and the [[Society of NeuroInterventional Surgery]].

Current [[recommendation]]s for [[management]] of cerebral vasospasm and DCI after [[aneurysmal subarachnoid hemorrhage]] (aSAH) are as follows:

Oral [[nimodipine]] should be administered to all patients with aSAH (class I; level of evidence). 

A) - It should be noted that this agent has been shown to improve neurologic outcomes but not cerebral vasospasm; the value of other calcium antagonists, whether administered orally or intravenously, remains uncertain
Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (class I; level of evidence, 

B) - Revised recommendation from previous guidelines
Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended(class III; level of evidence, 

B) - New recommendation
Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (class IIa; level of evidence, 

B) - New recommendation
Perfusion imaging with computed tomography (CT) or magnetic resonance imaging (MRI) can be useful to identify regions of potential brain ischemia (class IIa; level of evidence, 

B) - New recommendation
Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (class I; level of evidence, 

B) - Revised recommendation from previous guidelines
Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (class IIa; level of evidence, B) -  Revised recommendation from previous guidelines

===== Level of Evidence 1 =====

[[Level of Evidence 1]]:

Maintain [[euvolemia]] and normal circulating [[blood volume]].

[[Induced hypertension]] unless [[blood pressure]] is elevated at baseline or if precluded by [[cardiac stent]]s
((Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida
RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P;
American Heart Association Stroke Council; Council on Cardiovascular Radiology
and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular
Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the
management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/american Stroke Association.
Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 
3. PubMed PMID: 22556195.)).

===== Level of Evidence 2 =====

[[Level of Evidence 2]]:

Endovascular [[angioplasty]] and or selective [[intraarterial vasodilator therapy]] is reasonable  for patients not responding rapidly to or candidates for [[induced hypertension]].

=====Management=====
Patients with clinical suspicion of vasospasm (DIND), or with transcranial doppler increases 0f > 50 cm/sec or with absolute velocities > 200:

Serial neuroexams: while important, sensitivity for [[CVS]]/[[DCI]] is limited in poor grade patients
((Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida
RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P;
American Heart Association Stroke Council; Council on Cardiovascular Radiology
and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular
Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the
management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare
professionals from the American Heart Association/american Stroke Association.
Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 
3. PubMed PMID: 22556195.)).

Bed rest, [[HOB]] elevated to ≈ 30º.

[[TED hose]] and/or sequential [[compression boot]]s.

Strict [[I and O]] measurements

[[STAT]] non contrast [[head CT]] to rule out hydrocephalus, cerebral edema, cerebral infarct or rebleed

Option: [[Perfusion CT]] or [[MRI]].

STAT bloodwork

[[Electrolyte]]s to rule out [[hyponatremia]]
((Wise BL. Syndrome of inappropriate antidiuretic hormone secretion after
spontaneous subarachnoid hemorrhage: a reversible cause of clinical
deterioration. Neurosurgery. 1978 Nov-Dec;3(3):412-4. PubMed PMID: 740140.
)).

[[CBC]] to assess [[rheology]] and rule out [[sepsis]] or [[anemia]].

[[ABG]] to rule out [[hypoxemia]].

Repeat [[TCD]] to detect changes indicative of vasospasm.

[[Arterial line]] to monitor [[BP]].

[[Pulmonary artery catheter]] to monitor [[Pulmonary wedge pressure]] and [[cardiac output]] when possible ([[central line]] to monitor [[CVP]] when pulmonary artery catheter cannot be placed).

Insert [[ICP monitor]] if [[ICP]] felt to be problematic, treat elevated ICP with [[mannitol]] or [[CSF]] [[drainage]] before institution hemodynamic augmentation (caution: the diuresis from mannitol in treating ICP may produce [[hypovolemia]]; also, exercise caution in lowering ICP with unsecured aneurysm).

Continue nimodipine therapy. Give via [[nasogastric tube]] if pt unable to swallow.

Administer oxygen to keep PO2 > 70 mm Hg.

Ensure euvolemia: Patients with SAH  often develop hypovolemia early in their course
((Maroon JC, Nelson PB. Hypovolemia in patients with subarachnoid hemorrhage:
therapeutic implications. Neurosurgery. 1979 Mar;4(3):223-6. PubMed PMID: 460553.
))
((Wijdicks EF, Vermeulen M, Hijdra A, van Gijn J. Hyponatremia and cerebral
infarction in patients with ruptured intracranial aneurysms: is fluid restriction
harmful? Ann Neurol. 1985 Feb;17(2):137-40. PubMed PMID: 3977297.
))
((Wijdicks EF, Vermeulen M, ten Haaf JA, Hijdra A, Bakker WH, van Gijn J. Volume
depletion and natriuresis in patients with a ruptured intracranial aneurysm. Ann 
Neurol. 1985 Aug;18(2):211-6. PubMed PMID: 4037761.
)).

Primary IV fluid is [[crystalloid]] , usually [[isotonic]] (e.g. Normal [[Saline]]).

Blood (whole or PRBC) when [[hematocrit]] drops < 40 %.

Colloid: Plasma fraction or 5 % albumin (at 100 ml/hr) to mantain 40 % Hct (if HCt is > 40 %, use crystalloids
((Vermeulen LC Jr, Ratko TA, Erstad BL, Brecher ME, Matuszewski KA. A paradigm
for consensus. The University Hospital Consortium guidelines for the use of
albumin, nonprotein colloid, and crystalloid solutions. Arch Intern Med. 1995 Feb
27;155(4):373-9. PubMed PMID: 7848020.
)).

Mannitol 20 % at 0,25 gm/kg/hr as a drip may improve rheologic properties of blood in the microcirculation (avoid hypovolemia from resultant diuresis).

Replace urinary output with [[crystalloid]] (if Hct < 40 %, than use 5 % albumin, usually @ ≈ 20-25 ml/hr)

Avoid Hetastarch (Hespan®) and dextran which impair coagulation.

ABG and H/H daily

Serum and urine electrolytes and osmolalities q 12 hr (creatinine elevations may indicate peripheral ischemia from vasopressors).

CXR daily

Frequent EKG

Initiate Hemodynamic augmentation (Triple H is a old concept) unless BP is elevated at baseline or cardiac stents preclude it) for 6 hours.

If no response to 6 hrs of Hemodynamic augmentation (Triple H is a old concept), or if Doppler or perfusion CT or MRI suggests vasospasm, patient is taken to angiography to confirm presence of vasospasm and for interventional neuroradiologic treatment (intraartrial verapamil, angioplasty....).

Move patient to the ICU and placed on hemodynamic augmentation (Triple H is a old concept) for 6 hours if this is not already instituted.

Option [[Perfusion CT]] or [[MRI]].

If no response to 6 hrs of Hemodynamic augmentation, or if [[Perfusion CT]] suggest vasospasm patient is taken to angiography to confirm presence of vasospasm and for interventional neuroradiological treatment (intraarterial [[verapamil]], [[angioplasty]]...)