Vasoespasmo cerebral relacionado a hiperglicemia en paciente con hemorragia subaracnoidea aneurismatica: caso clínico y revisión de la literatura / Cerebral vasospasm related to hyperglycemia in patient with subaracoid aneurysmatic haemorrhage: clinical case and review of literature

La hemorragia subaracnoidea aneurismática es un fenómeno muy grave asociado a altas tasas de morbimortalidad, esta depende de la severidad inicial. El control de la glucosa es uno de los cuidados que se debe tener en cuenta ya que está estrechamente relacionada con el desarrollo de las complicaciones secundarias. Se presenta el caso clínico de un paciente con antecedente de diabetes tipo 2 tratada irregularmente, que presentó una hemorragía subaracnoidea aneurismática, complicada con vasoespasmo cerebral, infarto, hidrocefalia secundaria e infecciones pulmonares en relación a hiperglicemia durante el post operatorio de difícil y refractario tratamiento. Exponemos los mecanismos fisiopatológicos que ocasionan alteraciones de los fenómenos de autorregulación vascular cerebral y en consecuencia trastornos de la perfusión cerebral que decaen sobre el estado neurológico del paciente, sobresaltando que el control de la glucemia en el transcurso de una hemorragia subaracnoidea puede ayudar a un mejor desenlace de los pacientes.

Aneurysmal subarachnoid hemorrhage is a very serious phenomenon associated with high rates of morbidity and mortality, this depends on the initial severity. The control of glucose is one of the care that must be taken into account since it is closely related to the development of secondary complications. We present the clinical case of a patient with a history of type 2 diabetes treated irregularly, who presented an aneurysmal subarachnoid hemorrhage, complicated by cerebral vasospasm, infarction, secondary hydrocephalus and pulmonary infections in relation to hyperglycemia during the post-operative period of difficult and refractory treatment. We expose the pathophysiological mechanisms that cause alterations in the cerebral vascular self-regulation phenomena and consequently cerebral perfusion disorders that decrease the neurological state of the patient, highlighting that the control of glycemia in the course of a subarachnoid hemorrhage can help a better outcome of the patients.

Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study / Efeitos do sulfato de magnésio e da milrinona sobre o vasoespasmo cerebral após hemorragia subaracnoidea por aneurisma: estudo randômico

Abstract Background: Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. Methods: The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500 mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5 µg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity ≥ 120 cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). Results: The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p < 0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p = 0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p = 0.036, p = 0.012, p = 0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p = 0.012). Conclusions: The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

Resumo Justificativa: A hemorragia subaracnoidea por aneurisma é uma importante causa de morte prematura e de incapacidade em todo o mundo. O sulfato de magnésio mostra um efeito neuroprotetor e reverte o vasoespasmo cerebral. A milrinona também é usada no tratamento de vasoespasmo cerebral. O objetivo do presente estudo foi comparar o efeito profilático do sulfato de magnésio e da milrinona sobre a incidência de vasoespasmo cerebral após hemorragia subaracnoidea. Métodos: O estudo incluiu 90 pacientes com hemorragia subaracnoidea por aneurisma randomicamente distribuídos (randomização simples) em dois grupos: sulfato de magnésio foi administrado em infusão de 500 mg.dia-1 sem dose de ataque durante 21 dias. O Grupo B recebeu milrinona em infusão de 0,5 µg.kg-1·min-1 sem dose de ataque durante 21 dias. O vasoespasmo cerebral foi diagnosticado pela velocidade média do fluxo sanguíneo cerebral na artéria cerebral envolvida (velocidade média do fluxo ≥ 120 cm.s-1), a deterioração neurológica por escala de coma de Glasgow ou angiografia (diminuição do diâmetro da artéria cerebral envolvida > 25%). Resultados: A velocidade média do fluxo sanguíneo cerebral diminuiu significativamente no grupo magnésio em comparação com o grupo milrinona nos dias 7, 14 e 21 (p < 0,001). A incidência de vasoespasmo cerebral diminuiu significativamente com o magnésio em comparação com milrinona (p = 0,007). A escala de coma de Glasgow melhorou significativamente no grupo magnésio em comparação com o grupo milrinona nos dias 7, 14 e 21 (p = 0,036, p = 0,012, p = 0,016, respectivamente). A incidência de hipotensão foi maior com milrinona do que com magnésio (p = 0,012). Conclusões: A incidência de vasoespasmo cerebral após hemorragia subaracnoidea por aneurisma foi significativamente menor e a escala de coma de Glasgow significativamente melhor com magnésio em comparação com milrinona. A milrinona foi associada a uma maior incidência de hipotensão e necessidade de dopamina e norepinefrina em comparação com o magnésio.

[Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]. / Efeitos do sulfato de magnésio e da milrinona sobre o vasoespasmo cerebral após hemorragia subaracnoidea por aneurisma: estudo randômico.

BACKGROUND: Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage. METHODS: The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5µg.kg-1.min-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%). RESULTS: The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012). CONCLUSIONS: The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

Vasoespasmo cerebral y déficit isquémico tardío en la hemorragia subaracnoídea aneurismática: guías para su manejo clínico / Cerebral vasospasm and delayed ischemic deficit in the aneurysmal subarachnoid hemorrhage: guidelines to its clinical management

La presente revisión del tema Vasoespasmo y Déficit Isquémico Cerebral tardío (DIT) en la Hemorragia subaracnoidea aneurismática tiene como objetivo actualizar su manejo, basado en las hipótesis mas aceptadas que se han logrado para explicar su patogénesis. Se efectúa una introducción con conceptos generales, se revisan las bases patogénicas del Vasoespasmo y se plantea su manejo, tomando en cuenta su diagnóstico, monitorización, profilaxis y manejo avanzado de acuerdo a las últimas Guías de Manejo Clínico y según medicina basada en las evidencias.

The objective of the present review on cerebral vasospasm and cerebral delayed isquemic deficit due to subarachnoid haemorrhage secondary to ruptured cerebral aneurysm, is to update their management, based on the most accepted pathophysiological hypotesis explaining their pathogenetic mechanisms. An introduction is performed presenting general concepts, review of the most recent research works explaining their pathogenesis, and the management is stated touching diagnosis, monitoring, prophylaxis, and advanced management according with the last clinical guidelines for his management using medicine based on evidences.

Ergotismo del sistema nervioso central: Reporte de dos muertes maternas asociadas a vasoespasmo cerebral por medicamentos derivados del ergot en Antioquia, Colombia, y revisión de la literatura / Ergotism of the central nervous system: Report of two maternal deaths associated with cerebral vasospasm due to ergot-derived drugs in Antioquia, Colombia, and review of the literature

Objetivo: presentar dos casos de muerte materna asociados al uso de medicamentos derivados del ergot (ergotismo agudo severo), y realizar una revisión de la literatura de la presentación de eventos adversos en el sistema nervioso central en puérperas expuestas a estos medicamentos. Materiales y métodos: se presentan dos casos de muerte materna posparto, el primero se asoció al uso de bromocriptina para supresión de lactancia y el segundo al uso metilergometrina para controlar hemorragia poscesárea. Las pacientes fueron atendidas en instituciones de tercer nivel de complejidad en la ciudad de Medellín, Colombia. Se realizó revisión de la literatura, registrada en la base de datos Medline vía PubMed. Los términos empleados para la búsqueda fueron: derivados del ergot, bromocriptina, angeítis cerebral posparto, ergotismo, enfermedad vascular cerebral posparto. Se buscaron, sin límite de tiempo, reportes de caso, reportes de series de caso y revisiones de tema. Se buscaron informes o alertas de seguridad de agencias reguladoras tales como: la Federal Drugs Administration (FDA), la European Medicines Agency (EMA) y del Instituto Nacional de Vigilancia de Medicamentos y Alimentos (Invima). Se consultaron artículos en inglés, francés y español. Resultados: se incluyeron 16 publicaciones que cumplieron con los criterios de búsqueda. Se lograron identificar 33 casos. Dos fueron fatales, uno asociado al uso de metilergonovina venosa para el alumbramiento y el otro a ergometrina oral usado como abortivo en la semana 20 de gestación. En las neuroimágenes predominan los hallazgos isquémicos (sugestivos de vasoespasmo cerebral). En tres casos se reportó hemorragia intracerebral, uno de estos fue un caso fatal. Los síntomas más frecuentes de presentación fueron la cefalea intensa, seguida de la convulsión. Solo en nueve casos se logró identificar el antecedente de hipertensión o preeclampsia, y en cuatro migraña. La indicación para el uso de bromocriptina en todos los casos fue suprimir la lactancia. En los tres casos reportados en que se usó metilergonovina fue para realizar alumbramiento. En el sistema de farmacovigilancia colombiano no se encontraron reportes de eventos adversos serios asociados a estos medicamentos. Conclusión: se debe reconocer el ergotismo del sistema nervioso central en el puerperio por el uso de medicamentos tales como la bromocriptina y la metilergonovina, como una entidad potencialmente fatal. Es importante crear una cultura de reporte de eventos adversos serios de estos medicamentos en nuestro país.

Objective: To report two cases of maternal death associated with ergot-derived drugs (acute sever ergotism), and to conduct and review of the literature on central nervous system adverse events during the postpartum period in women exposed to these medications. Materials and methods: Two cases of maternal death during the postpartum period. The first was associated with the use of bromocriptine for breast milk suppression, and the second was associated with the use of methylergometrine for the control of bleeding after Cesarean section. The patients received care at Level III institutions in the city of Medellín, Colombia. A review of the literature was conducted in the Medline database through Pubmed. The terms used for the search were: ergot derivatives, bromocriptine, postpartum cerebralangiitis, ergotism, postpartum cerebral vascular disease. The search was conducted without a time limitation and included, case reports, case series reports, and reviews. The search also included safety reports or alerts from regulatory agencies such as the FDA, the European Medicines Agency (EMA), and Invima. Articles in English, French and Spanish were reviewed. Results: Overall, 16 publications that met the search criteria were included, and 33 cases were identified. Two of the cases were fatal, one associated with the use of intravenous methylergonovine for delivery and the second one was associated with the use of oral ergometrine to induce abortion at 20 weeks of gestation. Neuroimaging studies show, predominantly, ischemic findings (suggestive of cerebral vasospasm). In three cases, intracranial haemorrhage was reported, and one of the three cases was fatal. The most frequent presenting symptoms were intense headache, followed by seizures. It was possible to identify a history of hypertension and/or preeclampsia only in nine cases, and a history of migraine in four. The vast majority of patients were otherwise healthy. In all the cases, the indication for using bromocriptine was breast milk suppression. In the three reported cases in which methylergonovine was used, the indication was to assist delivery. No reports of serious adverse events associated with these drugs were found in the Colombian pharmacovigilance system. Conclusion: Ergotism of the central nervous system due to the use of drugs such as bromocriptine and methylergonovine must be recognised during the postpartum period because it is life-threatening. It is important to create a culture of reporting of serious adverse events associated with these medications in our country.

Intervenciones de enfermería en la persona con vasoespasmo cerebral secundario a hemorragia subaracnoidea aneurismática / Nursing interventions in the person with a secondary cerebral vasospasm aneurysmal subarachnoid haemorrhage

Introducción. El vasoespasmo cerebral como complicación de la Hemorragia subaracnoidea aneurismática, es considerado como una vasoconstricción patológica de las arterias principales de la base del encéfalo; es una condición reversible, que se caracteriza con la reducción del calibre de la luz de las arterias y por lo consiguiente una disminución del flujo sanguíneo al área perfundida por el vaso comprometido. Objetivo. Desarrollar un proceso enfermero basado en la taxonomía Nanda, Noc, Nic a una persona con vasoespasmo cerebral. Metodología. Se realizó la elección de un caso clínico, con la metodología del proceso de atención de enfermería estableciendo un plan de cuidados en el área de recuperación y terapia intermedia del Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez durante el periodo postquirúrgico inmediato. Se detectaron las necesidades básicas alteradas al realizar la valoración neurológica de enfermería. Se procedió a formular los diagnósticos de enfermería reales y de riesgo y con base en estos se planearon las intervenciones de enfermería. Conclusión. El realizar las intervenciones de enfermería de forma sistematizada a partir del proceso enfermero, se establece un método científico, en donde cada intervención se fundamenta y da pauta a la aplicación de un cuidado especializado, dirigido hacia la mejora de la persona desde el punto de vista individual y con ello detectar oportunamente signos y síntomas de alarma así como posibles complicaciones.

Introduction. The cerebral vasospasm as complication of the Haemorrhage subarachnoid aneurismática, is considered to be a pathological vasoconstriction of the main arteries of the base of the brain; it is a reversible condition, which is characterized by the reduction of the caliber of the light of the arteries and for consequent a decrease of the blood flow to the area perfundida for the awkward glass. Target. To develop a process nurse based on the taxonomy Nanda, NOC, NIC to a person with vasospasm cerebral. Methodology. There was realized the election of a clinical case, with the methodology of the process of attention of infirmary establishing a care plan in the field of recovery and intermediate therapy of the National Institute of Neurology and Neurosurgery Manuel Velasco Suárez during the immediate postsurgical period. The basic needs were detected altered on having realized the neurological infirmary evaluation. One proceeded to formulate the real diagnoses of infirmary and of risk and with base in these the infirmary interventions were planned. Conclusion. Realizing the interventions of infirmary of form systematized from the process nurse, establishes a scientific method, where every intervention is based and gives rule to the application of a specializing care, directed to the progress of the person from the individual point of view and with it to detect opportunely signs and symptoms of alarm as well as possible complication.

Signaling pathways in cerebral vasospasm / Vias sinalizadoras em vasoespasmo cerebral

Cerebral vasospasm is a deadly complication following the rupture of intracranial aneurysms. One new development in the experimental treatment of cerebral vasospasm is the looming target of signaling pathways. The pathogenesis of cerebral vasospasm involves multiple signaling pathways in proliferation, inflammation, cell death, smooth muscle phenotype changes, vascular remodeling, and contraction. A review of all of these areas is beyond the scope of this article, and as such, three systems that mediate these vascular responses have been selected: the tyrosine kinase-MAP kinase pathway, the sphingosine-1-Rho myosin light chain kinase pathway and protein kinase C.

O vasoespasmo cerebral é a complicação mais grave após a ruptura de um aneurisma intracraniano. Um novo foco experimental de tratamento de vasoespasmo cerebral são as vias sinalizadoras. A patogênese do vasoespasmo cerebral envolve múltiplas vias de sinalização na proliferação, inflamação, morte celular, alterações fenotípicas da muscultura lisa, remodelamento vascular e contração. Uma revisão de todas essas áreas é o objetivo deste artigo, e três sistemas que comandam essa resposta vascular foram selecionados: a via da tirosina quinase-MAP quinase, a via esfingosina-1-Rho miosina quinase e a proteína quinase C.

Utilidad del doppler transcraneal en la hemorragia subaracnoidea: revisión / Usefulness of transcranial doppler in subarachnoid hemorrhage: review

This review summarizes the usefulness of transcranial Doppler (TCD) for the assessment of subarachnoid hemorrhage in the setting of a stroke unit. The basic hemodynamic principles are presented. We discuss the accuracy, the advantages and limitations of the TCD and the interpretation methods.

Esta revisión resume la utilidad del Doppler transcraneal (DTC) para la evaluación de la hemorragia subaracnoidea en instalaciones de una unidad de tratamiento de accidente vascular. Se presentan los principios hemodinámicos básicos. Se discute la eficiencia, las ventajas y las limitaciones del DTC y los métodos de interpretación.

Uso de simvastatina en la prevención de la isquemia cerebral en la hemorragia subaracnoídea aneurismática / Use of simvastatin in brain ischemia prevention in aneurysmal subarachnoid hemorrhage

Introducción: El vasoespasmo cerebral es una complicación temida y aun no resuelta en los pacientes que cursan con hemorragia subaracnoídea neurismática (HSA), y que significa una importante morbi-mortalidad en dichos pacientes. Material y métodos: Se revisaron los registros de 161 pacientes ingresados en el Hospital Carlos Van Buren de Valparaíso por HSA entre entre Mayo de 2007 y Agosto de 2009, comparando la aparición de complicaciones isquémicas y resultados funcionales, según fuesen o no tratados con Simvastatina (40 mg/día). Resultados: El grupo de pacientes tratados con Simvastatina presentó significativamente menos infartos cerebrales (9,30 por ciento vs. 24,58 por ciento, p=0,02) y menos mortalidad intrahospitalaria (1,24 por ciento vs. 11,80 por ciento, p=0,04). Conclusiones: Si bien el diseño del estudio impide atribuir las diferencias encontradas al uso de Simvastatina, dado el contexto del mismo, es muy probable que así sea. El uso de estatinas en la hemorragia subaracnoídea aneurismática, como profilaxis del vasoespasmo es aún un tema controversial y promisorio, que se encuentra en plena etapa de estudio y desarrollo.

Background: Vasospasm is a feared complication in patients who present with aneurysmal subarachnoid hemorrhage (SAH) and that means significant morbidity and mortality in these patients. Material and methods: We reviewed the records of 161 patients admitted to the Hospital Carlos Van Buren with SAH between May 2007 and August 2009, comparing the occurrence of ischemic complications and functional results as they were or not treated with simvastatin (40mg/day). Results: The patient group treated with simvastatin had significantly fewer strokes (p = 0.02) and fewer hospital mortality (p = 0.04). Conclusions: Although the study design precludes attributing the differences found when using simvastatin, given the context, it is likely to be so. The use of statins in aneurismal subarachnoid hemorrhage for vasospasm prophylaxis is still a controversial and promising topic, wich is under full development and study.