Cervical sympathectomy to treat cerebral vasospasm: a scoping review

Abstract

Background/ImportanceDelayed cerebral ischemia (DCI) is the second-leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (aSAH), and is associated with cerebral arterial vasospasm (CAV). Current treatments for CAV are expensive, invasive, and have limited efficacy. Cervical sympathetic block (CSB) is an underappreciated, but potentially highly effective therapy for CAV.ObjectiveTo provide a comprehensive review of the preclinical and human literature pertinent to CSB in the context of CAV.Evidence reviewThis study followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. We conducted a literature search using Embase, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science until February 2022, to identify abstracts, conference proceedings, and full-text papers pertinent to cervical sympathectomy and CAV in animal/adult patients.FindingsWe included six human and six experimental studies. Human studies were mostly prospective observational, except one retrospective and one randomized clinical trial, and used various imaging modalities to measure changes in arterial diameter after the block. Studies that used digital subtraction angiography showed an improvement in cerebral perfusion without change in vessel diameter. Transcranial Doppler studies found an approximately 15% statistically significant decrease in velocities consistent with arterial vasodilatation. Overall, the results suggest an increase in cerebral arterial diameter and neurological improvement in patients receiving a CSB. Animal studies demonstrate that sympathetic system ablation vasodilates cerebral vasculature and decreases the incidence of symptomatic vasospasm.ConclusionsThis scoping review suggests that CSB may be a viable option for treatment and prevention of CAV/DCI in patients with aSAH, although the included studies were heterogeneous, mostly observational, and with a small sample size. Further research is needed to standardize the technique and prove its effectiveness to treat patients suffering of CAV/DCI after aSAH.

Auricular Vagus Nerve Stimulation Mitigates Inflammation and Vasospasm in Subarachnoid Hemorrhage: A Randomized Trial

“…Following SAH, there is a widespread sympathetic response, which can manifest with increased risk for cerebral vasospasm, delayed cortical ischemia, and extracerebral organ damage 39 . VNS may restore the SAH-induced autonomic imbalance by enhancing parasympathetic input 40,41 . Another phenomenon observed in SAH patients is cortical spreading depolarizations (CSDs), with evidence of a causal relationship between CSDs and worse neurological outcomes 42 .…”

Regional anesthesia for head and neck neurosurgical procedures: a narrative review in adult and pediatric patients

“…79 The findings from the literature on sympathetic blocks for patients suffering from vasospasm after aSAH highlight the potential of using regional anesthesia not only as a complementary analgesic technique to general anesthesia but also as a means to improve short-term and long-term neurological outcomes in patients with cerebrovascular disorders. 80…”

Severe Cerebral Vasospasm Caused by Acute on Top of Chronic Spontaneous Subdural Hematoma: A Case Report and Review of the Literature

“…Cerebral vasospasm is a well-known phenomenon in the context of subarachnoid hemorrhage (SAH) secondary to cerebral arterial aneurysms. It is also associated with other pathologies such as traumatic brain injury, reversible cerebral vasoconstriction syndrome, post-tumor resection surgery, and other non-aneurysmal SAHs [ 1 , 2 ]. The occurrence of severe symptomatic clinical vasospasm is infrequent clinically in contexts other than aneurysmal SAH or other forms of severe brain insult [ 2 ].…”

“…It is also associated with other pathologies such as traumatic brain injury, reversible cerebral vasoconstriction syndrome, post-tumor resection surgery, and other non-aneurysmal SAHs [ 1 , 2 ]. The occurrence of severe symptomatic clinical vasospasm is infrequent clinically in contexts other than aneurysmal SAH or other forms of severe brain insult [ 2 ]. To our knowledge, this case report is the first to report such a complication following a non-traumatic acute on top of chronic non-traumatic subdural hematoma (SDH) in a patient with absent corpus callosum.…”