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Anaesthesia May 2005Subarachnoid haemorrhage is a common neurological emergency, which carries a high morbidity and mortality. It is usually caused by rupture of an intracerebral aneurysm... (Review)
Review
Subarachnoid haemorrhage is a common neurological emergency, which carries a high morbidity and mortality. It is usually caused by rupture of an intracerebral aneurysm or, less commonly, an arteriovenous malformation. Although most patients present to a non-neurosurgical hospital, they often require urgent neurosurgical or neuroradiological intervention. Whilst awaiting transfer to a neurological centre, active management of the patient must be instituted. This should include confirmation of the diagnosis with CT imaging, lumbar puncture or both, and recognition of the complications of subarachnoid haemorrhage, which include hydrocephalus, further haemorrhage and cerebral vasospasm. Medical management is directed towards maintaining adequate cerebral perfusion pressure whilst avoiding large increases in arterial blood pressure. Nimodipine therapy must be started early in an attempt to prevent cerebral vasospasm. The treatment options available at the neurological centre include surgical treatment or endovascular obliteration of the aneurysm or arteriovenous malformation.
Topics: Emergency Service, Hospital; Female; Humans; Intracranial Aneurysm; Intracranial Arteriovenous Malformations; Male; Neurosurgical Procedures; Patient Transfer; Pregnancy; Pregnancy Complications, Cardiovascular; Subarachnoid Hemorrhage; Tomography, X-Ray Computed; Vasospasm, Intracranial
PubMed: 15819768
DOI: 10.1111/j.1365-2044.2005.04152.x -
Interventional Neurology Oct 2018Although it is well characterized in aneurysmal subarachnoid hemorrhage, vasospasm is exceedingly rare following cerebral arteriovenous malformation (AVM) rupture....
BACKGROUND
Although it is well characterized in aneurysmal subarachnoid hemorrhage, vasospasm is exceedingly rare following cerebral arteriovenous malformation (AVM) rupture. Subsequently, this complication is poorly characterized with regard to delayed cerebral ischemia (DCI). We review cases of ruptured AVM to assess the frequency and severity of vasospasm on cerebral angiography, and DCI.
SUMMARY
We reviewed our institutional database of acute intracranial hemorrhages between 2005 and 2014. We identified patients with cerebral AVM rupture and evidence of vasospasm, which was confirmed with digital subtraction angiography (DSA). Cerebral angiograms were evaluated by 2 blinded neurointerventionalists for vasospasm. Statistical analyses were conducted on the angiographic results and variables of interest to determine predictors and associations of vasospasm and DCI. Thirty-six patients with acute intracranial hemorrhage due to ruptured cerebral AVM subsequently underwent cerebral angiography. The interrater reliability for vasospasm was 0.81. The incidence of vasospasm was 13.9% and the incidence of subsequent DCI was 11.1%. A significant relationship existed between isolated intraventricular hemorrhage and vasospasm ( = 0.001) and subsequent DCI ( = 0.006). Radiographic vasospasm was associated with DCI in 80% of the patients ( < 0.0001). No statistical significance existed between subarachnoid hemorrhage and the development of vasospasm or DCI ( = 1.000 and = 0.626, respectively). All differences were significant at a 99% level of significance.
KEY MESSAGE
In cases of ruptured AVM, isolated intraventricular hemorrhage appears to be an independent risk factor for vasospasm and DCI. Vasospasm must be considered during late neurological deterioration following AVM hemorrhage, especially in the setting of isolated intraventricular hemorrhage.
PubMed: 30410528
DOI: 10.1159/000490583 -
Internal Medicine (Tokyo, Japan) 2017Objective To evaluate the outcomes of patients with concomitant Brugada syndrome and coronary artery vasospasm. Methods Patients diagnosed with Brugada syndrome with an...
Objective To evaluate the outcomes of patients with concomitant Brugada syndrome and coronary artery vasospasm. Methods Patients diagnosed with Brugada syndrome with an implantable cardiac defibrillator were retrospectively investigated, and the coexistence of vasospasm was evaluated. The clinical features and outcomes were evaluated, especially in patients with coexistent vasospasm. A provocation test using acetylcholine was performed in patients confirmed to have no organic stenosis on percutaneous coronary angiography to confirm the presence of vasospasm. Implantable cardiac defibrillator shock status was checked every three months. Statistical comparisons of the groups with and without vasospasm were performed. A univariate analysis was also performed, and the odds ratio for the risk of implantable cardiac defibrillator shock was calculated. Patients Thirty-five patients with Brugada syndrome, of whom six had coexistent vasospasm. Results There were no significant differences in the laboratory data, echocardiogram findings, disease, or the history of taking any drugs between patients with and without vasospasm. There were significant differences in the clinical features of Brugada syndrome, i.e. cardiac events such as resuscitation from ventricular fibrillation or appropriate implantable cardiac defibrillator shock. Four patients with vasospasm had cardiac events such as resuscitation from ventricular fibrillation and/or appropriate defibrillator shock; three of them had no cardiac events with calcium channel blocker therapy to prevent vasospasm. The coexistence of vasospasm was a potential risk factor for an appropriate implantable cardiac defibrillator shock (odds ratio: 13.5, confidence interval: 1.572-115.940, p value: 0.035) on a univariate analysis. Conclusion Coronary artery vasospasm could be a risk factor for cardiac events in patients with Brugada syndrome.
Topics: Adult; Brugada Syndrome; Coronary Angiography; Coronary Vasospasm; Defibrillators, Implantable; Electrocardiography; Female; Humans; Male; Middle Aged; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 28090040
DOI: 10.2169/internalmedicine.56.7307 -
British Journal of Anaesthesia Apr 2013Transcranial Doppler measurements of the middle cerebral artery flow velocity are widely used as an indicator of vasospasm after aneurysmal subarachnoid haemorrhage...
BACKGROUND
Transcranial Doppler measurements of the middle cerebral artery flow velocity are widely used as an indicator of vasospasm after aneurysmal subarachnoid haemorrhage (SAH). We investigated inter- and intraoperator agreement in SAH patients and healthy volunteers using colour-coded transcranial Doppler (TCCD), with the secondary aim of describing prediction of angiographic vasospasm and mortality.
METHODS
Sixty patients and 70 healthy controls were each examined in duplicate by alternating operators. A total of 939 measurements divided on 201 examination sets were conducted by four observers. The Bland-Altman limits of agreement (LoA) were calculated using a variance components analysis. Angiography was performed on clinical indication and survival recorded at 30 days.
RESULTS
Differences between measurements increased with increasing average, and therefore, we analysed log-transformed values. Thus, LoA are given as ratios between measurements. There were no systematic intra- or interobserver differences (bias). The intraobserver LoA was 0.62-1.61 in patients and 0.67-1.50 in controls. However, they were 0.55-1.82 in patients with angiographic vasospasm, whereas in patients without, they were 0.66-1.52. The interobserver LoA was 0.55-1.81 in patients and 0.65-1.55 in controls, while in patients with and without angiographic vasospasm, they were 0.45-2.22 and 0.60-1.67, respectively. Flow velocity measurements day 6-10 were positively associated with 30 day mortality risk (P=0.02, logistic regression).
CONCLUSIONS
TCCD measurement variability is wider in patient measurements than in controls. This discrepancy can largely be explained by a higher degree of error in patients with angiographic vasospasm. Despite the considerable measurement variability in TCCD, values are predictive of outcome in SAH.
Topics: Adult; Aged; Aged, 80 and over; Algorithms; Angiography, Digital Subtraction; Cerebral Angiography; Cerebrovascular Circulation; Female; Forecasting; Humans; Male; Middle Aged; Middle Cerebral Artery; Observer Variation; Prospective Studies; Subarachnoid Hemorrhage; Tomography, X-Ray Computed; Ultrasonography, Doppler, Transcranial; Vasospasm, Intracranial; Young Adult
PubMed: 23257989
DOI: 10.1093/bja/aes458 -
Neurologia (Barcelona, Spain) Jun 2013Delayed vasospasm has traditionally been considered the most important determinant of poor outcome after subarachnoid haemorrhage (SAH). Consequently, most of the... (Review)
Review
INTRODUCTION
Delayed vasospasm has traditionally been considered the most important determinant of poor outcome after subarachnoid haemorrhage (SAH). Consequently, most of the research and therapies are directed towards reducing the incidence of vasospasm (VSP). To date, however, clinical trials based on this strategy have not delivered a definitive treatment for preventing or reducing brain injury after SAH. This fact has caused a paradigm shift in research, which now focuses on early brain injury (EBI) occurring in the first 72 hours after SAH. It has also changed the idea of VSP's role in brain damage, and suggests the need for re-evaluating the pathophysiological process of SAH.
DEVELOPMENT
This review examines the current state of knowledge on the pathophysiological mechanisms associated with EBI and summarises the diagnostic options currently available.
CONCLUSION
It seems that the research approach needs to be changed so that investigators will focus on prevention of EBI, reduction of secondary brain complications and ultimately, the optimisation neurological outcome.
Topics: Biomarkers; Brain; Disease Progression; Humans; Neuroimaging; Prognosis; Subarachnoid Hemorrhage; Treatment Outcome; Vasospasm, Intracranial
PubMed: 22264777
DOI: 10.1016/j.nrl.2011.10.015 -
Journal of Medical Case Reports Feb 2022BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile...
BACKGROUND
BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population.
CASE PRESENTATION
Here, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy.
CONCLUSIONS
This case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children.
Topics: Autonomic Nervous System Diseases; Child; Craniocerebral Trauma; Humans; Hypertension; Male; Vasospasm, Intracranial; Wounds, Penetrating
PubMed: 35123564
DOI: 10.1186/s13256-022-03254-5 -
Proceedings of the National Academy of... Aug 2011Vasospasm of the cerebrovasculature is a common manifestation of blast-induced traumatic brain injury (bTBI) reported among combat casualties in the conflicts in...
Vasospasm of the cerebrovasculature is a common manifestation of blast-induced traumatic brain injury (bTBI) reported among combat casualties in the conflicts in Afghanistan and Iraq. Cerebral vasospasm occurs more frequently, and with earlier onset, in bTBI patients than in patients with other TBI injury modes, such as blunt force trauma. Though vasospasm is usually associated with the presence of subarachnoid hemorrhage (SAH), SAH is not required for vasospasm in bTBI, which suggests that the unique mechanics of blast injury could potentiate vasospasm onset, accounting for the increased incidence. Here, using theoretical and in vitro models, we show that a single rapid mechanical insult can induce vascular hypercontractility and remodeling, indicative of vasospasm initiation. We employed high-velocity stretching of engineered arterial lamellae to simulate the mechanical forces of a blast pulse on the vasculature. An hour after a simulated blast, injured tissues displayed altered intracellular calcium dynamics leading to hypersensitivity to contractile stimulus with endothelin-1. One day after simulated blast, tissues exhibited blast force dependent prolonged hypercontraction and vascular smooth muscle phenotype switching, indicative of remodeling. These results suggest that an acute, blast-like injury is sufficient to induce a hypercontraction-induced genetic switch that potentiates vascular remodeling, and cerebral vasospasm, in bTBI patients.
Topics: 1-(5-Isoquinolinesulfonyl)-2-Methylpiperazine; Algorithms; Arteries; Blast Injuries; Blotting, Western; Brain Injuries; Calcium; Calcium Channel Blockers; Cells, Cultured; Cytosol; Endothelin-1; Gene Expression; Humans; Military Medicine; Models, Biological; Muscle Contraction; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Myosin Heavy Chains; Reverse Transcriptase Polymerase Chain Reaction; Stress, Mechanical; Tissue Engineering; Vasospasm, Intracranial; Warfare
PubMed: 21765001
DOI: 10.1073/pnas.1105860108 -
Neurocritical Care Aug 2020Though there are many biomarker studies of plasma and serum in patients with aneurysmal subarachnoid hemorrhage (SAH), few have examined blood cells that might...
BACKGROUND
Though there are many biomarker studies of plasma and serum in patients with aneurysmal subarachnoid hemorrhage (SAH), few have examined blood cells that might contribute to vasospasm. In this study, we evaluated inflammatory and prothrombotic pathways by examining mRNA expression in whole blood of SAH patients with and without vasospasm.
METHODS
Adult SAH patients with vasospasm (n = 29) and without vasospasm (n = 21) were matched for sex, race/ethnicity, and aneurysm treatment method. Diagnosis of vasospasm was made by angiography. mRNA expression was measured by Affymetrix Human Exon 1.0 ST Arrays. SAH patients with vasospasm were compared to those without vasospasm by ANCOVA to identify differential gene, exon, and alternatively spliced transcript expression. Analyses were adjusted for age, batch, and time of blood draw after SAH.
RESULTS
At the gene level, there were 259 differentially expressed genes between SAH patients with vasospasm compared to patients without (false discovery rate < 0.05, |fold change| ≥ 1.2). At the exon level, 1210 exons representing 1093 genes were differentially regulated between the two groups (P < 0.005, ≥ 1.2 |fold change|). Principal components analysis segregated SAH patients with and without vasospasm. Signaling pathways for the 1093 vasospasm-related genes included adrenergic, P2Y, ET-1, NO, sildenafil, renin-angiotensin, thrombin, CCR3, CXCR4, MIF, fMLP, PKA, PKC, CRH, PPARα/RXRα, and calcium. Genes predicted to be alternatively spliced included IL23A, RSU1, PAQR6, and TRIP6.
CONCLUSIONS
This is the first study to demonstrate that mRNA expression in whole blood distinguishes SAH patients with vasospasm from those without vasospasm and supports a role of coagulation and immune systems in vasospasm.
Topics: Adult; Aged; Aneurysm, Ruptured; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Principal Component Analysis; RNA, Messenger; Subarachnoid Hemorrhage; Transcriptome; Vasospasm, Intracranial
PubMed: 31595394
DOI: 10.1007/s12028-019-00861-x -
Neuroradiology Dec 2009Vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is thought to cause ischemia. To evaluate the contribution of vasospasm to delayed cerebral ischemia (DCI), we...
INTRODUCTION
Vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is thought to cause ischemia. To evaluate the contribution of vasospasm to delayed cerebral ischemia (DCI), we investigated the effect of vasospasm on cerebral perfusion and the relationship of vasospasm with DCI.
METHODS
We studied 37 consecutive SAH patients with CT angiography (CTA) and CT perfusion (CTP) on admission and within 14 days after admission or at time of clinical deterioration. CTP values (cerebral blood volume, cerebral blood flow (CBF) and mean transit time), degree of vasospasm on CTA, and occurrence of DCI were recorded. Vasospasm was categorized as follows: no spasm (0-25% decrease in vessel diameter), moderate spasm (25-50% decrease), and severe spasm (>50% decrease). The correspondence of the flow territory of the most spastic vessel with the least perfused region was evaluated, and differences in perfusion values and occurrence of DCI between degrees of vasospasm were calculated with 95% confidence intervals (95% CI).
RESULTS
Fourteen patients had no vasospasm, 16 were moderate, and seven were severe. In 65% of patients with spasm, the flow territory of the most spastic vessel corresponded with the least perfused region. There was significant CBF (milliliters per 100 g per minute) difference (-21.3; 95% CI, -37 <--> -5.3) between flow territories of severe and no vasospasm. Four of seven patients with severe, six of 16 with moderate, and three of 14 patients with no vasospasm had DCI.
CONCLUSION
Vasospasm decreases cerebral perfusion, but corresponds with the least perfused region in only two thirds of our patients. Furthermore, almost half of patients with severe vasospasm do not have DCI. Thus, although severe vasospasm can decrease perfusion, it may not result in DCI.
Topics: Adult; Aged; Brain Ischemia; Cerebral Angiography; Cerebrovascular Circulation; Female; Humans; Male; Middle Aged; Perfusion Imaging; Subarachnoid Hemorrhage; Vasospasm, Intracranial
PubMed: 19623472
DOI: 10.1007/s00234-009-0575-y -
Trauma Case Reports Jun 2019Coronary vasospasm is characterized by focal or diffuse spasm of an epicardial coronary artery. Definitive diagnosis is usually made with coronary angiography, when...
Coronary vasospasm is characterized by focal or diffuse spasm of an epicardial coronary artery. Definitive diagnosis is usually made with coronary angiography, when resolution of stenosis is observed after administration of intracoronary vasodilators. Coronary vasospasm is rarely a consequence of a blunt force injury to the chest. Among trauma induced cardiac complications, coronary vasospasm has been the least common with only one other reported case of coronary vasospasm induced by trauma. We report a rare case of severe spontaneous coronary vasospasm in a patient with polytrauma successfully treated with intracoronary, intravenous and oral vasodilator therapy. The mechanism is thought to be due to compensatory catecholamine response to trauma, and coronary vasospasm should be strongly suspected in trauma patients with unexplained hypotension, new conduction abnormalities or evidence of ischemia on the ECG.
PubMed: 31049387
DOI: 10.1016/j.tcr.2019.100194