Vasospasm treatment in the large cerebral arteries did not improve mortality or functional outcomes 1) 2).
It is only partially treatable 3) 4).
Efforts to remove the blood in the basal cisterns as the agent for cerebral vasospasm etiology by surgery, cisternal, or external ventricular drainage showed mixed results 5) 6) 7).
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 +/- Inotropes/vasopressors
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
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 8).
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 grades compared to the other group.
This data indicate that CSF drainage reduces the risk of vasospasms in patients with endovascular treatment for aneurysmal SAH 9).
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.