Celia Bradford on Vasospasm after SAH

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Information about Celia Bradford on Vasospasm after SAH
Health & Medicine

Published on March 5, 2014

Author: oliflower

Source: slideshare.net

Description

Celia Bradford talks about prevention and management of vasospasm after subarachnoid haemorrhage. This talk was recorded at Bedside Critical Care Conference 4.

Vasospasm After SAH PREVENTION AND M A N AG E M E NT

Prevalence  0.5% of the population will rupture a cerebral aneurysm  25% of these will die  Death is due to  The initial catastrophic bleed  Rebleeding  Cerebral vasospasm

Vasospasm  70% of patients will have angiographic evidence of spasm following the haemorrhage  30% of these cases will have symptomatic spasm  50% of these will have DIND

VASOSPASM  Delayed cerebral vasospasm typically develops from 4 to 9 days, though earlier (3 days) or late (3 weeks) vasospasm may be observed

Does spasm = ischemia?  Not necessarily  Many factors contribute to the development of ischemia and infarction,  distal microcirculatory failure,  Poor collateral anatomy,  genetic or physiological variations in cellular ischemic tolerance

Risks for Spasm

Case  50 year old woman  Sudden onset of headache

ED->CTB; SAH. Ruptured AComA aneurysm

Coiling

Progress  EVD inserted for hydrocephalus  Extubated on day 4.  GCS 14 (eyes to voice) but generally drowsy  On day 8 developed left hemiparesis  Intubated  DSA demonstrated severe bilateral ICA spasm  Balloon angioplasty to RICA and MCA  Intraarterial verapamil and papaverine

Progress  Massive doses of noradrenaline and vasopressin to maintain SBP. ICP high. Thio coma  Angio D9... Severe spasm persists refractory to intraarterial verapamil  CTB; diffuse cerebral oedema. ICPs >30  Decompressive craniectomy

Progress  D10;  Despite decompression, ICP remain at 38.  Unsupportable BP  Therapy ceased

Diagnosis  Neuro exam  DSA  TCD  Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class IIa;Level of Evidence B). (New recommendation)  Warning Signs  CT Perfusion

A=CBF B=CBV

Perfusion imaging can be useful to identify regions of potential brain ischaemia (Class IIa; Level of evidence B)

Management

Management; 6 point plan  1.Nimodipine 2. Euvolemia 3. Induction of Hypertension 4. Mg 5. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy 6. Stop the boats

Nimodipine  Level 1 Evidence

Euvolemia and Hypertensing  Choice of fluid  SBP aims

Magnesium

Intra-arterial therapy

Management of other complications due to vasospasm  Hyponatremia... Cerebral salt wasting  Role of euvolemia  Fludrocortisone  3% saline  Choice of fluid

Fever Independent association with high fever after SAH and poor cognitive outcome

Haemoglobin  Controversial  Lower threshold for transfusion in vasospastic patients

Statins  STASH Trial

Other  Urokinase  Lumbar drainage

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