Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management

Abstract

Background: The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). Methods:This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery).Results: Eighty patients aged 8.6 years (3.3-14.8 years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). Conclusions:These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.

Balloon angioplasty for the treatment of cerebral vasospasm

“…However, other authors de ne DCI as the sudden onset of neurological de cit, transient or not, associated with angiographic con rmation of vessel narrowing in the corresponding territory [4]. The physiopathology of DCI involves several mechanisms that decrease cerebral blood ow (CBF) and lead to tissue ischemia and cerebral infarction [2,7]. Transcranial Doppler (TCD) monitoring helps to detect vasospasm, especially in sedated or comatose patients, and a recent consensus stated recommendations for children [12].…”

“…Aneurysmal SAH is rare in childhood [5], and the reported incidence of associated DCI in children is around 25% − 53% [4,10,13,17]. Cerebral vasospasm's is usual de nition is an arterial diameter reduction greater than 50% compared to admission diameter on brain imaging [7]. However, other authors de ne DCI as the sudden onset of neurological de cit, transient or not, associated with angiographic con rmation of vessel narrowing in the corresponding territory [4].…”

“…Even without medical treatment, DCI usually has better outcomes in children than adults, probably due to collateral circulation. However, there are no speci c guidelines for managing DCI in children, with only a few descriptions in the literature [7,14]. Therefore, physicians often adapt adult treatment guidelines to pediatric patients [10].…”

“…In most cases, DCI begins four days after bleeding, the narrowing is maximal at 6-8 days, and it resolves up to 2-3 weeks after bleeding [5]. Although well characterized in aneurysmal SAH, DCI can occur after hemorrhage due to trauma, arteriovenous malformations (AVM), tumors, coagulopathies, vasculitis, and intracranial surgeries [5,7,14,15]. DCI is rare in childhood but can lead to severe neurological de cits or death [7,14].…”

“…Although well characterized in aneurysmal SAH, DCI can occur after hemorrhage due to trauma, arteriovenous malformations (AVM), tumors, coagulopathies, vasculitis, and intracranial surgeries [5,7,14,15]. DCI is rare in childhood but can lead to severe neurological de cits or death [7,14]. In addition, data is lacking to establish treatment recommendations and reduce risks for children.…”