Management of Arterial Vasospasm Following Aneurysmal Subarachnoid Hemorrhage

Abstract

Despite recent advances, cerebral vasospasm and delayed cerebral ischemia (DCI) still represent a major cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). In general, aSAH affects 30,000 North Americans annually, representing 5 to 10% of all cases of stroke, primarily affecting individuals aged 40 to 60 years although it can occur at all ages. 1,2 Although aSAH is less common than ischemic forms of stroke, it commonly affects younger patients and therefore is often associated with an even greater impact in terms of productive life years lost and higher medical costs in both the acute and follow-up periods. 3,4 Although a significant portion of the morbidity and mortality associated with aSAH is related to the initial hemorrhagic ictus, cerebral vasospasm and its related cerebral injury, which typically occurs within 3 to 7 days of hemorrhage and can last through 21 days posthemorrhage, 5 is still the leading cause of poor outcomes and death in the acute posthemorrhage period, causing long-term disability or death in more than one in five of all patients who have suffered aSAH and initially survived. 6 Following aSAH, angiographically detectable vasospasm of the cerebral arteries occurs in 50 to 90% of patients. 7 Approximately two-thirds of aSAH patients will suffer from vasospasm that is at least moderate in severity. Although some of these cases will remain asymptomatic, of these, approximately half will become symptomatic and half of these will develop neuroimaging findings of cerebral infarction, correlating strongly with poor outcomes in these individuals. 8 Although recent advances in the acute management of patients following aSAH have reduced the incidence of these poor outcomes related to cerebral vasospasm, it still remains a leading cause of clinical deterioration and poor outcomes following aSAH. Most recent studies demonstrate an overall risk of death and AbstractDespite recent advances, cerebral vasospasm and delayed cerebral ischemia (DCI) still represent a major cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Although a significant portion of the morbidity and mortality associated with aSAH is related to the initial hemorrhagic ictus, cerebral vasospasm and DCI are still the leading cause of poor outcomes and death in the acute posthemorrhage period, causing long-term disability or death in more than one in five of all patients who have suffered aSAH and initially survived. Management of patients following aSAH includes four major considerations: (1) prediction of patients at highest risk for development of DCI, (2) prophylactic measures to reduce its occurrence, (3) monitoring to detect early signs of cerebral ischemia, and (4) treatments to correct vasospasm and cerebral ischemia once it occurs. The authors review the pertinent literature related to each, including both the current management guidelines supported by the literature as well as novel management strategies that are currently being investigated.

SIRT3 Expression Decreases with Reactive Oxygen Species Generation in Rat Cortical Neurons during Early Brain Injury Induced by Experimental Subarachnoid Hemorrhage

“…Recently, a large body of aneurysmal SAH literature has indicated strongly that early brain injury (EBI) might play a more pivotal role in neurological impairment and poor prognosis after SAH [6, 7]. EBI is associated with various pathophysiological processes including blood-brain barrier disruption, brain swelling, and dramatic increase of intracranial pressure, occurring within the first 72 h secondary to SAH [8].…”

Association of travel distance and cerebral aneurysm treatment

“…Although a significant body of evidence suggests that only a minority of aneurysms eventually rupture,[ 1 30 32 ] aneurysmal subarachnoid hemorrhage remains a significant cause of morbidity and mortality. [ 7 12 ] The inherent complexities of the management of aneurysms—both ruptured and unruptured—combined with advancements in both imaging and treatment modalities mean that these patients are best treated at high-volume centers with deep subspecialty expertise. [ 37 ] The availability of such care; however, is limited by both a dearth of vascular and endovascular neurosurgeons[ 34 ] and a geographic maldistribution of practitioners, with the majority of counties in the United States having no neurosurgeons at all.…”

“…The shortage of healthcare professionals is not limited to neurosurgery, and significant discussion is ongoing in both the medical literature[ 13 35 36 39 42 ] and the popular press[ 12 31 ] about how best to tackle this difficult issue. One of the results of this deficiency is the need for extended travel by some patients to obtain primary and specialty medical care.…”

Risk Factors for Postoperative Cerebral Vasospasm After Surgical Resection of Acoustic Neuroma

“…Identifying risk factors for cerebral vasospasm can facilitate the use of prophylaxis, early diagnosis, and timely intervention (8).…”