Diapositiva 1

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Cerebral Vasospasm post Subarachnoid
Hemorrhage Pathophysiological bases for its
Treatment General considerations Pathop
hysiology Treatment

Prof. Dr. Leónidas Quintana
Chief of Neurosurgery Service Van
Buren Hospital
Cathedra of Neurosurgery

Valparaíso University School of Medicine, Chile
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AT THE WILLIS CIRCLE THE CEREBRAL VASOSPASM IS
REALLY A SPASM ?
Ecker A., Riemenschneider P.A. Arteriographic
demonstration of spasm of the intracranial
arteries with special reference to saccular
arterial aneurysms. J. Neurosurg. 1951,
8660-667.
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PATHOPHYSIOLOGY OF CEREBRAL VASOSPASM
Oxy Hb
Sonobe M,Suzuki J Vasospasmogenic substance
produced following subarachnoid hemorrhage and
its fate . Acta Neurochir(Wien) 4497-106,1978
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1
Asano T,Tanishima T et alsPossible participation
of Free Radical Reactions initiated by clot lysis
in the Pathogenesis of Vasospasm after
Subarachnoid Hemorrhage. In Cerebral Arterial
Spasm.Proceedings of the Second International
Workshop,pp190-201(WilkinsRH ed),BaltimoreWilliam
sWilkins,1980.
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Quintana L,Konda R,Ishibashi Y,Yoshimoto T,
Suzuki J.The Effect of Prostacyclin on Cerebral
Vasospasm- An Experimenta Study. Acta
Neurochirurgica 62,187-193, 1982.
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CAM
2 Inflammation
Chaichana KL, Pradilla G, Huang J, Tamargo RJ
Role of inflammation (leukocyte-endothelial cell
interactions) in vasospasm after subarachnoid
hemorrhage. World Neurosurg 7322-41, 2010.
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3 Endothelial Dysfunction
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Cortical Spreading Depression Cortical
Spreading Ischemia
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Na/K pump Ca pump ATP dependent
Membrane failure
Intracranial Hypertension due to global increase
CBV during aneurysm rupture, and difusse decrease
of CBF
Regional or focal decrease of CBF at
microcirculation level (real spasm)
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DELAYED ISCHEMIC DEFICIT SECONDARY TO
CEREBRAL VASOSPASM THE REAL
VASOSPASM
Ischemia K e , Na i , Ca i
Pre-clipping
Microcirculation Delayed Ischemic Deficit
During ischemia
Vasospasm Narrowing due to ultrastructural
alterations
gt 50 stenosis
Post-clipping
Sundt Th M Jr,Davis DHReactions of
cerebrovascular smooth muscle to blood and
ischemiaPrimary versus Secondary Vasospasm.In
Cerebral Arterial Spasm.Wilkins RH
(ed),Baltimore,WilliamsWilkins, pp 244-250,1980.
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TREATMENT OF CEREBRAL VASOSPASM
Level Microcirculation Delayed Ischemic
Deficit 1-Haemodynamic Management- Induced
Hypertension, Hypervolemia2-Calcium Antagonists
Level Willis Circle Angiographycal Symptomatic
Vasospasm 1-Prophylaxis Early Surgery with
cisternal washing, Fenestration of Lamina
terminalis, drainage of basal cisterns,
evacuation of ICH (Modern concept of Integrated
Management of the Disease SAH) 2-Therapeutic
Management Endovascular Angioplasty
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HAEMODYNAMIC THERAPY
Disautoregulation during SAH
Takeuchi H,Handa Y et alsImpairment of cerebral
autoregulation during the development of chronic
cerebral vasospasm after subarachnoid hemorrhage
in primates.Neurosurgery 2841-48,1991.
CBF CPP ( MAP - ICP) n x r 4
8 x v x L
The triple H therapy is recommended for
prevention and treatment of the ischemic
complications due to cerebral vasospasm. Its
recommended to perform more clinical trials to
establish its real efficacy. ( evidence level
III-V, grade C ) Circulation 902592-2605,1994.
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CALCIO ANTAGONISTS
Nimodipine is strongly recommended for
diminishing the bad results at the outcome, due
to DID secondary to vasospasm. (Evidence level
I-II strenght of recommendation A) Circulation
902592-2605,1994.
Nimodipine improved the evolution of SAH due to
ruptured aneurysm (good vs other and good or
moderate vs other) in a ratio 1,861 and
1,671 Nimodipine decreased the probability of
deficit and/or mortality due to vasospasm in a
ratio of 0,461 Nimodipine decreased the
probability of ischemic complications at CT
scan in a ratio of 0,581
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TOPICAL NIMODIPINE
I.V. NIMODIPINE
ACTION OF NIMODIPINE ON CEREBRAL CORTICAL

ARTERIES ARTERIES OF 1mm 40
VASODILATION ARTERIES OF 160-300 u 100
VASODILATION ARTERIES OF lt 100 u 200
VASODILATION
Quintana L.Acción de la Nimodipina en el
Déficit Isquémico Retardado de la HSA (Action of
Nimodipine on Delayed Ischemic Deficit of SAH),
Rev. Chil. Neurocirug, Vol. 2 (3), 239-250,1988.
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MECHANICAL PHARMACOLOGICAL ANGIOPLASTY
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THANK YOU VERY MUCH !!!


Prof. Dr. Leónidas Quintana
Chief of Neurosurgery Service Van
Buren Hospital
Cathedra of Neurosurgery

Valparaíso University School of Medicine, Chile