====== Cerebral Vasospasm Treatment ====== [[Vasospasm]] [[treatment]] in the large cerebral arteries did not improve mortality or functional outcomes ((Macdonald RL, Higashida RT, Keller E, et al. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2).  Lancet Neurol. 2011;10(7):618-625. doi:10.1016/S1474-4422(11)70108-9)) ((Macdonald RL, Higashida RT, Keller E, et al. Randomized trial of clazosentan in patients with aneurysmal subarachnoid hemorrhage undergoing endovascular coiling.  Stroke. 2012;43(6):1463-1469. doi:10.1161/STROKEAHA.111.648980)). It is only partially treatable ((Macdonald RL, Weir BK. A review of hemoglobin and the pathogenesis of cerebral vasospasm. Stroke 1991;22(08):971–982)) ((Pluta RM. Delayed cerebral vasospasm and nitric oxide: review, new hypothesis, and proposed treatment. Pharmacol Ther 2005; 105(01):23–56)). ---- Efforts to remove the [[blood]] in the [[basal cistern]]s as the agent for [[cerebral vasospasm etiology]] by surgery, cisternal, or [[external ventricular drainage]] showed mixed results ((Mao J, Zhu Q, Ma Y, Lan Q, Cheng Y, Liu G. Fenestration of lamina terminalis during anterior circulation aneurysm clipping on occurrence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: meta-analysis.  World Neurosurg. 2019;129:e1-e5. doi:10.1016/j.wneu.2019.01.270)) ((Roelz R, Schaefer JH, Scheiwe C, et al. Impact of stereotactic ventriculocisternostomy on delayed cerebral infarction and outcome after subarachnoid hemorrhage.  Stroke. 2020;51(2):431-439. doi:10.1161/STROKEAHA.119.027424)) ((Kasuya H, Shimizu T, Kagawa M. The effect of continuous drainage of cerebrospinal fluid in patients with subarachnoid hemorrhage: a retrospective analysis of 108 patients.  Neurosurgery. 1991;28(1):56-59.)). ---- The ultimate goal in the treatment of [[cerebral vasospasm]] after [[subarachnoid hemorrhage]] is to avoid [[DIND]] by reducing ICP, optimizing the rate of cerebral oxygen demand, and improving cerebral blood flow. Given these goals, early aneurysm treatment and ventriculostomy placement for patients with elevated intracranial pressure is a necessity. Early aneurysm treatment allows the treatment team to be more aggressive with further vasospasm treatment over the course of care. IVF +/- [[Inotrope]]s/[[vasopressor]]s [[CVP]] 10-12mmHg, [[PAOP]] 15-18mmHg, [[CI]] 3-3.5 L/min/m2, [[Hct]] 30-35%, [[SBP]] 160-200 if aneurysm clipped and 120-150 if unclipped ===== Nimodipine ===== see [[Nimodipine for vasospasm]]. ===== Intrathecal nicardipine ===== [[Intrathecal nicardipine]] ===== Prevention ===== [[Cerebral Vasospasm Prevention]] ===== Triple H therapy for cerebral vasospasm ===== [[Triple H therapy for cerebral vasospasm]] ==== For refractory Triple H therapy ==== Selective intra-arterial verapamil, papaverine, or nitroprusside or Angioplasty. ---- Hemodynamic strategies and endovascular procedures may be considered for the treatment of [[cerebral vasospasm]]. To date, the current therapeutic interventions remain ineffective being limited to the manipulation of systemic blood pressure, variation of blood volume and viscosity, and control of arterial carbon dioxide tension.In this scenario, the hormone erythropoietin (EPO), has been found to exert neuroprotective action during experimental SAH when its recombinant form (rHuEPO) is systemically administered. However, recent translation of experimental data into clinical trials has suggested an unclear role of recombinant human EPO in the setting of SAH ((Grasso G, Tomasello G, Noto M, Alafaci C, Cappello F. Erythropoietin for the treatment of subarachnoid hemorrhage: A feasible ingredient for a successful medical recipe. Mol Med. 2015 Nov 16. doi: 10.2119/molmed.2015.00177. [Epub ahead of print] PubMed PMID: 26581085. )). ===== Papaverine ===== see [[Papaverine for cerebral vasospasm]]. ===== Intra-arterial Infusion of Calcium Channel Blocker ===== [[Intra-arterial Infusion of Calcium Channel Blocker]]. ==== CSF diversion ==== A substantial body of evidence supports the idea that CSF diversion could prevent VS, even if this issue is still much debated. [[External ventricular drainage]] (EVD) is the recommended procedure for [[posthemorrhagic hydrocephalus]]. Of radiologically confirmed VS in 141 patients treated endovascularly for [[aneurysmal subarachnoid hemorrhage]]: 80 underwent EVD for [[hydrocephalus]], 61 did not undergo EVD. VS occurred in 8.75% of cases (7 patients) in the first groups, while in 22.95% (14 patients) in the second group. In addition, patients not treated with EVD display a prevalence of VS in lower [[Fisher grade]]s compared to the other group. This data indicate that CSF drainage reduces the risk of [[vasospasm]]s in patients with [[endovascular treatment]] for aneurysmal SAH ((Della Pepa GM, Scerrati A, Albanese A, Marchese E, Maira G, Sabatino G. Protective effect of external ventricular drainage on cerebral vasospasm. A retrospective study on aneurysmal SAH treated endovascularly. Clin Neurol Neurosurg. 2014 Sep;124:97-101. doi: 10.1016/j.clineuro.2014.06.030. Epub 2014 Jun 28. PubMed PMID: 25019459.)). ==== Cervical Sympathetic Nerve Block ==== [[Cervical Sympathetic Nerve Block for cerebral vasospasm]]. ===== Balloon angioplasty ===== Endovascular procedures such as intraarterial (IA) vasodilator injection and [[balloon angioplasty]] are used to treat medically refractory cerebral vasospasm. The effects of IA therapy may be short-lived and thus require multiple treatments. Balloon angioplasty also has limitations including transient occlusion of the spastic blood vessel, possible endothelial injury, and limited access to proximal vessels. ---- Stent retrievers have several benefits over balloon angioplasty for the treatment of vasospasm. Stent retrievers are non-occlusive, conform easily to the curvature of the vessel, and have a known, safe opening force that prevents vessel rupture. In contrast to balloon angioplasty, stent retrievers have limited surface interface with the lumen, theoretically resulting in less endothelial injury. ===== Stent-retriever ===== [[Stent-retriever for Cerebral Vasospasm Treatment]].