Vasospasm management

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Preventive

Pravastatin 40mg daily and nimodipine 60mg every 4 hours PO or via NG tube for 21 days should be initiated within 4 days of hemorrhage as they have both been shown to improve outcome in vasospasm (1,2). Calcium channel blockers are thought to be more so neuroprotective than counteractive to vasospasm itself. Their benefit may derive from their prevention of calcium entry into ischemic cells, anti-platelet effect (3), and ability to dilate leptomeningeal arteries (4). While nimodipine does not alter radiographic vasospasm (5), outcome is overall improved (6). Patients should be monitored for renal failure, GI side effects, dependent edema and pulmonary edema, potential side effects of calcium channel blocker use.

Endothelin receptor antagonists (clazosentan), still under investigation, may reduce both the frequency (40% versus 88% in a control group for angiographic vasospasm) and severity of vasospasm (7).

When suspicion arises:


  • Hyperdynamic Therapy – Hypertension, Hypervolemia, Hemodilution (see article on triple H therapy for more details)
  • CBC, CMP, ABG, Head CT to rule out other components of the differential diagnosis (see article)
  • EKG, Echo, and enzymes should be drawn to assess LV function
  • Perfusion CT or MRI
  • Angiography with possible transluminal balloon angioplasty (TBA) for larger vessels or intra-arterial drug injection (IAD) of verapamil, papavarine, or nicardipine for smaller vessels or to facilitate TBA.

References

1. Barker F G, Ogilvy C S: Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: A metaanalysis. J Neurosurg 84: 405-14, 1996.

2. Tseng MY, Hutchinson PJ, Czosnyka M, Richard H, Pickard JD, Kirkpatrick PJ: Effects of acute pravastatin treatment on intensity of rescue therapy, length of inpatient stay, and 6-month outcome in patients after aneurismal subarachnoid hemorrhage. Stroke 2007: 38(5), 1545-50.

3. Dale J, Landmark K H, Myhre E: The effects of nifedipine, a calcium channel antagonist, on platelet function. Am Heart J 105: 103-5, 1983.

4. Auer L M: Pial arterial vasodilatation by intravenous nimodipine in cats. Drug Research 31: 1423-5, 1981.

5. Allen G S, Ahn H S, Preziosi T J et al.: Cerebral arterial spasm - A controlled trial of nimodipine in patients with subarachnoid hemorrhage. N Engl J Med 308: 619-24, 1983.

6. Barker F G, Ogilvy C S: Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: A metaanalysis. J Neurosurg 84: 405-14, 1996.

7. Vajkoczy P, Meyer B, Weidauer S, et al.: Clazosentan, a selective endothelin A receptor antagonist, in the prevention of a cerebral vasospasm following severe aneurysmal subarachnoid hemorrhage: Results of a randomized, double-blind, placebo-controlled, multicenter phase IIa study. J Neurosurg 103: 9-17: 2005.

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