Peri-operative measures for treatment and prevention of cerebral vasospasm following subarachnoid hemorrhage.
OBJECTIVE
Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high early mortality rates. Cerebral vasospasm remains the major source of morbidity after aSAH. Angiographic evidence of vasospasm is apparent in 70% of patients, while clinical manifestation of vasospasm is present in one third of patients. Early or existing vasospasm at the time of presentation poses an additional challenge in the management of the patient, and forms the basis for this review.


METHODS
Treatment modalities for management of ruptured aneurysms in the setting of vasospasm, including timing of aneurysm surgery and peri-operative management, are reviewed. Intraoperative measures aimed at treatment of existing vasospasm and at the prevention of vasopasm are discussed.


RESULTS
Operative/endovascular means to secure the ruptured aneurysm should be performed as soon as possible to facilitate treatment of the vasospasm. Surgery performed in the presence of angiographic/symptomatic vasospasm can be associated with good outcome. Operative measures to decrease the incidence of vasospasm include clot removal, intracisternal injection of thrombolytics, fenestration of the lamina terminalis and local application of vasodilatory agents. Post-operative measures include early intra-arterial injection of vasodilators (verapamil or nicardipine), percutaneous angioplasty, triple-H therapy and CSF drainage.


CONCLUSIONS
The utilization of a multimodality approach to treat patients with aneurysmal subarachnoid hemorrhage presenting with existing vasospasm can result in good outcome.
Alaraj
Ali
A
Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612-5970, USA.
Charbel
Fady T
FT
Amin-Hanjani
Sepideh
S
D017542:Aneurysm, Ruptured / Q000628:therapy; D002533:Cerebral Angiography; D002985:Clinical Protocols; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care / Q000379:methods; D011300:Preoperative Care / Q000379:methods*; D013345:Subarachnoid Hemorrhage / Q000150:complications; D014057:Tomography, X-Ray Computed; D020301:Vasospasm, Intracranial / Q000188:drug therapy / Q000517:prevention & control / Q000601:surgery / Q000628:therapy