Elsevier

Surgical Neurology

Volume 56, Issue 3, September 2001, Pages 140-148
Surgical Neurology

Vascular
Contemporary management of subarachnoid hemorrhage and vasospasm: the UIC experience

https://doi.org/10.1016/S0090-3019(01)00513-4Get rights and content

Abstract

BACKGROUND

Cerebral vasospasm is a well-known and serious complication of aneurysmal subarachnoid hemorrhage. The means of monitoring and treatment of vasospasm have been widely studied. Each neurosurgical center develops a protocol based on their experience, availability of equipment and personnel, and cost, so as to keep morbidity and mortality rates as low as possible for their patients with vasospasm.

METHODS

At the University of Illinois at Chicago, we have developed algorithms for the diagnosis and management of cerebral vasospasm based on the experience of the senior authors over the past 25 years. This paper describes in detail our approach to diagnosis and treatment of aneurysmal subarachnoid hemorrhage and vasospasm. Our discussion is highlighted with data from a retrospective analysis of 324 aneurysm patients.

RESULTS

Over 3 years, 324 aneurysms were treated; 185 (57%) were clipped, 139 (43%) were coiled. The rate of vasospasm for the 324 patients was 27%. The rate of hydrocephalus was 32% for those patients who underwent clipping, and 29% for those coiled. The immediate outcomes for those who underwent clipping was excellent in 35%, good in 38%, poor in 15.5%, vegetative in 3%, and death in 8% of the patients. For those who underwent coiling the immediate outcome was excellent in 64%, good in 14.5%, vegetative in 2.5%, and death in 14.5% of the patients. These statistics include all Hunt and Hess grades.

For those patients who underwent clipping, 51% were intact at 6 months follow-up, 15% had a permanent deficit, 10% had a focal cranial nerve deficit, and 2% had died from complications not directly related to the procedure. For those patients who had undergone coiling, 75% were intact at 6 months follow-up, 12.5% had a permanent deficit, and 12.5% had a cranial nerve deficit, with no deaths.

CONCLUSIONS

The morbidity and mortality of cerebral vasospasm is significant. A good outcome after aneurysmal subarachnoid hemorrhage is dependent upon careful patient management in the preoperative, perioperative, and postoperative periods. The timely work-up and aggressive treatment of neurological deterioration, whether or not it is because of vasospasm, is paramount.

Section snippets

Diagnosis and initial management

The heralding symptoms of SAH include sudden headache, nuchal rigidity, mental status changes, and focal cranial nerve or motor deficits, and are indications for emergency CT scan of the brain. At our institution we perform a plain (nonenhanced) CT scan. If CT scan is negative for hemorrhage, lumbar puncture (LP) is performed and the cerebrospinal fluid (CSF) is analyzed for xanthrochromia. Any patient with the diagnosis of SAH, suspected SAH despite negative CT scan or LP, or suspicion of an

Initial studies and blood pressure control

Once in the NSICU, central venous and arterial lines are placed for fluid and blood pressure management. Routine blood tests are performed including arterial blood gasses, complete blood count, serum electrolytes, and coagulation studies, as well as a base-line electrocardiogram and chest X-ray. If the patient is known not to have hypertension, a nitroprusside drip is started and the patient’s systolic blood pressure is maintained below 110 mmHg. If the patient has a history of hypertension

Nimodipine

Patients in the NSICU receive neurological examinations and have their vital signs (including CVP and ICP) measured every hour because of the rapid changes in neurological status that can occur in SAH patients. Patients on any vasoactive drips including nitroprusside have their vital signs measured every 15 minutes. All patients are started on oral nimodipine (60 mg every 4 hours). This calcium channel blocker has been shown to improve long-term neurological outcome in SAH patients who suffer

Fisher grading and Hunt-Hess grading

Based upon the patient’s admission CT scan the patient is assigned a Fisher grade. Based upon their neurological status, they are assigned a Hunt–Hess grade. Figure 1, Figure 2display the Fisher grades and Hunt–Hess grades for those patients presenting with SAH who underwent clipping or coiling. These data are derived from a 3-year retrospective analysis of 324 aneurysm patients.

Angiography

As soon as the patient is stabilized, urgent cerebral angiography is performed. At our institution a four-vessel cerebral angiogram with digital subtraction including views of both extracranial and intracranial vessels is performed on all patients presenting with SAH. This is performed as soon as possible after the diagnosis of SAH, usually within the first 6 to 12 hours after hemorrhage.

Ventricular drainage

A ventricular drainage catheter is often placed in those patients who have evidence of hydrocephalus on CT scan. If a patient who does not have significantly enlarged ventricles needs ICP monitoring we still advocate the use of a ventriculostomy catheter because it affords a means of monitoring intracranial pressure (ICP) as well as lowering it (CSF drainage). This principle also becomes important in the management and optimization of cerebral perfusion pressure (CPP). The judgment for the

Timing of surgery or coiling

Once an aneurysm is identified, the patient usually undergoes craniotomy and clipping or endovascular coiling as soon as possible, usually within 24 hours. If for some reason it is necessary to postpone surgery and it is felt that the aneurysm is at risk for re-rupture because of its size or geometry, the patient is started on an infusion of epsilon amino-caproic acid (IV bolus of 5 grams in 100 ml saline over 1 hour, followed by a continuous infusion of 1 gram per hour). Although reports 20

Postoperative management

A postoperative CT scan is performed on all surgical patients usually within 1 to 4 hours of clipping or coiling. This scan is performed to rule out any peri-procedural hemorrhage, contusion, or hydrocephalus, and at the same time to establish a baseline examination for future reference. Once an aneurysm is secured, the patient’s blood pressure parameters are liberalized. If there is any immediate evidence of unexpected postoperative deficit that cannot be explained based upon CT findings, or

Evaluation of neurological deterioration

It is important to detect vasospasm before the patient suffers delayed ischemic neurological deficit or stroke. Any patient who is at risk for postoperative vasospasm and has symptoms of neurological deterioration or mental status changes undergoes emergency cerebral angiogram to rule out vasospasm. Attention is paid to the daily TCD velocities as well as to the other possibilities within the differential diagnosis such as hyponatremia, seizure, cerebral edema, and hydrocephalus, but until

Treatment of vasospasm

Angiographic evidence of vasospasm is treated immediately with balloon angioplasty of all accessible arterial segments that demonstrate evidence of spasm. These include the proximal and supraclinoid internal carotid arteries, vertebral and basilar arteries, and proximal segments of the middle cerebral arteries. We have found it technically difficult to navigate an angioplasty catheter into the anterior cerebral arteries and so it is frequently not possible to treat the A1 segment of the

New modalities for monitoring vasospasm patients

Because of the poor understanding of the pathophysiologic mechanism of vasospasm, further investigation is needed. New ways of treating vasospasm and new methods for diagnosing vasospasm are yet to be discovered. The use of the INVOS transcutaneous cerebral oximeter (Somanetics Corporation, Troy, MI), a cutaneous sensor capable of measuring cortical oxygen saturation, is a new means of monitoring for vasospasm 14, 30. We apply the cutaneous sensor pads on both sides of the forehead. Although

Conclusions

Obtaining good outcomes in patients presenting with subarachnoid hemorrhage is dependent upon careful and aggressive preoperative, perioperative, and postoperative care. Often a patient who presents with a low-grade bleed and who undergoes successful aneurysm clipping can suffer severe postoperative complications leading to a dismal outcome. Patients with subarachnoid hemorrhage and vasospasm can be the sickest patients a neurosurgeon might encounter. Careful attention to detail in every aspect

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