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1.
Acta Neurochir Suppl ; 127: 127-138, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31407073

RESUMO

BACKGROUND: Because treatments for cerebral arterial spasm-a delayed consequence of subarachnoid hemorrhage (SAH)-are clinically inconsistent, we describe here a new method for reversal of arterial spasm, possibly extensible to nitric oxide (NO)-sensitive microvasculature. METHODS: We subjected dogs to the intracisternal double-hemorrhage model of SAH (autologous blood injection on days 1 and 3) and began endovascular treatment of the spasmed basilar artery (BA) on Day 4. A conical-tip fused silica optical fiber was introduced via a microcatheter (inserted femorally) into the proximal vicinity of the spasmed BA. After local saline flushing of blood, an ultraviolet (UV) pulsed laser beam (355 nm Nd:YAG) was focused into the optical fiber and converted into a concentric ring beam, which facilitated endovascular irradiation for 30 s at intensities of 12-20 W/cm2. BA diameters were measured angiographically using a semiautomated routine over the entire BA length as well as the proximal, medial, and distal segments. RESULTS: On Day 4 the BAs had constricted by 21 ± 11%. After UV laser irradiation on Day 4, the constricted BAs dilated to 93 ± 15% of their normal diameters within minutes, and the dilation (91 ± 12%) persisted on Day 5. Most BA segments recovered to their respective baselines after UV irradiation, even when the UV beam was located considerably proximal to the BA origin. At days 4 and 5, the percent BA dilation normalized to Day 4 pre-treatment decreased linearly (by scatter plot, p < 0.02) over a range of about 60 mm from the UV irradiation site. CONCLUSIONS: We conjecture that the vasodilator nitric oxide, produced at high local concentration from its vascular storage forms (chiefly nitrites) by UV laser-induced photoscission, stimulates a wave of arterial dilation, possibly by longitudinal propagation of transnitrosation reactions in the arterial wall, which reverses cerebral vasospasm semi-locally and thus avoids the deleterious effects of systemic treatment.


Assuntos
Terapia a Laser , Hemorragia Subaracnóidea , Vasoespasmo Intracraniano , Animais , Artéria Basilar , Cães , Espasmo , Hemorragia Subaracnóidea/complicações , Raios Ultravioleta , Vasoconstrição , Vasoespasmo Intracraniano/etnologia , Vasoespasmo Intracraniano/terapia
3.
Neurology ; 93(5): e458-e466, 2019 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-31278116

RESUMO

OBJECTIVE: Delayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts. MATERIALS: Data from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed. RESULTS: The final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome. CONCLUSIONS: A preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.


Assuntos
Angioplastia com Balão/métodos , Isquemia Encefálica/prevenção & controle , Procedimentos Endovasculares/métodos , Nimodipina/administração & dosagem , Hemorragia Subaracnóidea/terapia , Vasodilatadores/administração & dosagem , Vasoespasmo Intracraniano/terapia , Adulto , Idoso , Pressão Arterial , Isquemia Encefálica/etiologia , Feminino , Mortalidade Hospitalar , Humanos , Infusões Intra-Arteriais , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/complicações , Fatores de Tempo , Vasoespasmo Intracraniano/complicações
5.
World Neurosurg ; 128: e956-e965, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31100528

RESUMO

BACKGROUND: Microsurgical management of blood blister aneurysms of the internal carotid artery is challenging because of the special characteristics of these aneurysms. We reviewed our diverse surgical methods with long-term clinical and radiologic follow-up. METHODS: We retrospectively reviewed all patients with blood blister aneurysms presenting with subarachnoid hemorrhage that were treated with microsurgical obliteration between 1993 and 2017. Baseline characteristics of patients and aneurysms, surgical methods, and clinical and radiologic outcomes were analyzed. RESULTS: This study included 36 patients. The patients were treated using microsurgery with direct clipping (2 patients; 5.6%), cotton-assisted clipping (24 patients; 66.7%), wrapping-clipping (5 patients; 13.9%), or wrapping-clipping with suturing (5 patients; 13.9%). Complete occlusion of aneurysm was achieved in 34 of 36 patients (94.4%). Severe vasospasm developed in 18 of 36 patients (50%). Ischemic events occurred in 8 patients (22.2%), 2 of whom remained with severe disability. Regrowth or recurrence occurred in 1 patient (0.28%), which required additional stent-assisted coil embolization. Mean modified Rankin Scale score was 2.0 (median, 1.0; range, 0-4) at discharge and 1.3 (median, 1.0; range, 0-4) at the last follow-up. CONCLUSIONS: Direct clipping is ideal if possible; however, direct clipping is challenging in most blood blister aneurysms. Assisted clipping with cotton is mainly used and could be an effective technique for reinforcement of the friable wall, with good clinical outcomes in our series. Moreover, suturing followed by wrapping-clipping is also useful for managing intraoperative rupture.


Assuntos
Aneurisma Roto/cirurgia , Vesícula/cirurgia , Artéria Carótida Interna/cirurgia , Revascularização Cerebral/métodos , Aneurisma Intracraniano/cirurgia , Adolescente , Adulto , Idoso , Embolização Terapêutica , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Estudos Retrospectivos , Hemorragia Subaracnóidea/cirurgia , Instrumentos Cirúrgicos , Suturas , Resultado do Tratamento , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/terapia , Adulto Jovem
6.
Interv Neuroradiol ; 25(5): 511-515, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31088245

RESUMO

Cerebral vasospasm is a source of morbidity and mortality, not only associated with aneurysmal subarachnoid hemorrhage (SAH) but also with endovascular procedures. Treatment of vasospasm associated with SAH include trans-luminal balloon angioplasty and intra-arterial delivery of vasodilator medications. We present a case report of a patient who underwent a mechanical thrombectomy for stroke and suffered from vasospasm. This severe flow-limiting vasospasm was successfully treated with the Trevo stent device. Although stent retrievers have become more widespread for thrombectomy, vasospasm treatment has not been often described in the literature. Further study is needed to determine if this is a viable technique for treating resistant vasospasm.


Assuntos
Doença Iatrogênica , Complicações Pós-Operatórias/terapia , Stents , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/terapia , Idoso , Angiografia Digital , Angioplastia , Isquemia Encefálica/cirurgia , Humanos , Masculino , Procedimentos Neurocirúrgicos , Acidente Vascular Cerebral/cirurgia , Trombectomia , Resultado do Tratamento , Vasodilatadores/administração & dosagem , Vasodilatadores/uso terapêutico
7.
World Neurosurg ; 128: 29-36, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31003025

RESUMO

BACKGROUND: Cerebral vasospasm causing delayed cerebral ischemia after transsphenoidal surgery is a rare but life-threatening complication. Reports in the literature after extended endoscopic endonasal approach (EEEA) are scarce. Considering the progressive use of this technique during recent years, a better understanding of the potential adverse effects after this procedure is needed. The aim of this report was to systematically analyze the current literature and discuss management and causes for cerebral vasospasm after EEEA surgery. METHODS: We performed a systematic search of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and aimed to discuss relevant risk factors for cerebral vasospasm after extended transsphenoidal surgery. RESULTS: Thirty-four cases of delayed cerebral vasospasm after transsphenoidal surgery were identified. Among these, 4 were operated with an EEEA. We provide an extensive literature review and discuss causes and management of this delayed complication. We further present the case of a young woman who underwent resection for a large suprasellar recurrent pituitary adenoma. Surgery and initial postoperative course were uneventful. On the eighth postoperative day, the patient developed aphasia and brachiofacial paresis. Digital subtraction angiography (DSA) demonstrated cerebral vasospasm, and repeated intra-arterial nimodipine infusion was administrated. The patient recovered completely and was discharged without neurologic deficits. CONCLUSIONS: The threshold for DSA after unexplained neurologic deterioration after extended transsphenoidal surgery should be low, and cerebral vasospasm should be treated early and aggressively. Surgeons performing EEEA need to consider the possibility of this delayed complication.


Assuntos
Adenoma/cirurgia , Cirurgia Endoscópica por Orifício Natural , Neuroendoscopia , Neoplasias Hipofisárias/cirurgia , Complicações Pós-Operatórias , Vasoespasmo Intracraniano/etiologia , Feminino , Humanos , Complicações Pós-Operatórias/terapia , Vasoespasmo Intracraniano/terapia , Adulto Jovem
8.
World Neurosurg ; 126: 513-527, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30898740

RESUMO

BACKGROUND: Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage. OBJECTIVE: To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era. METHODS: A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage. RESULTS: Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy. CONCLUSIONS: Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.


Assuntos
Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/terapia , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/terapia , Animais , Isquemia Encefálica/complicações , Procedimentos Endovasculares/métodos , Humanos , Fármacos Neuroprotetores/uso terapêutico , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/complicações
9.
Neurol India ; 67(1): 185-200, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30860121

RESUMO

This article highlights the pathogenesis and management of cerebral vasospasm. It discusses the various pharmacological, endovascular, and neurosurgical approaches available for the treatment of cerebral vasospasm. Numerous drugs and procedures have been tried and tested in the management of cerebral vasospasm. We try to highlight the pros and cons of various pharmacological agents and case-based use of other not so popular and investigational techniques.


Assuntos
Isquemia Encefálica/terapia , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/terapia , Isquemia Encefálica/etiologia , Humanos , Vasoespasmo Intracraniano/etiologia
10.
J Neuroradiol ; 46(1): 15-24, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29733918

RESUMO

BACKGROUND AND PURPOSE: Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (SAH). Arterial cerebral vasospasm (CVS) is discussed as the main pathomechanism for DCI. Due to positive effects of per os nimodipine, intraarterial nimodipine application is used in patients with DCI. Further, percutaneous transluminal balloon angioplasty (PTA) is applied in focal high-grade spasm of intracranial arteries. However, clinical benefits of those techniques are unconfirmed in randomized trials so far, and complications might occur. We analyzed the occurrence of new infarcts in patients with severe CVS treated intra-arterially to assess benefits and risks of those techniques in a large single-center collective. MATERIALS AND METHODS: All imaging and clinical data of 88 patients with CVS after SAH and 188 procedures of intraarterial nimodipine infusion and additional PTA in selected cases (18 patients, 20 PTA procedures) treated at our institution were reviewed. In the event of new infarcts after endovascular treatment of CVS, infarct patterns were analyzed to determine the most probable etiology. RESULTS: Fifty-three percent of patients developed new cerebral infarction after intraarterial nimodipine and additional PTA in selected cases. Hereunder 47% were caused by persisting CVS. In 6% of patients, 3% of procedures respectively, new infarcts occurred due to complications of the intraarterial treatment including thromboembolism and arterial dissection. Of those, 3% of patients, 2% of procedures respectively, were assigned to thrombembolic complications of digital substraction angiography for intraarterial nimodipine. 17% of all patients treated with PTA (3/18=17%) showed infarction as a complication of PTA (15% of all PTA procedures). In 1% of patients, etiology of new infarction remained unclear. CONCLUSION: Ischemic complications occur in about 6% of patients treated intraarterially for CVS, 3% of procedures respectively. Further, to date a benefit for patients treated with this therapy could not be proven. Therefore, intraarterial treatment of CVS should be performed only in carefully selected cases.


Assuntos
Angioplastia , Nimodipina/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Hemorragia Subaracnóidea/complicações , Vasodilatadores/uso terapêutico , Vasoespasmo Intracraniano/terapia , Adulto , Idoso , Aneurisma Dissecante/diagnóstico por imagem , Aneurisma Dissecante/epidemiologia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/epidemiologia , Terapia Combinada , Feminino , Humanos , Infusões Intra-Arteriais , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/epidemiologia , Masculino , Pessoa de Meia-Idade , Nimodipina/administração & dosagem , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Retrospectivos , Hemorragia Subaracnóidea/diagnóstico por imagem , Tromboembolia/diagnóstico por imagem , Tromboembolia/epidemiologia , Resultado do Tratamento , Vasodilatadores/administração & dosagem , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologia
11.
World Neurosurg ; 122: e1014-e1019, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30414522

RESUMO

OBJECTIVE: The purpose of this study was to evaluate the association between noninfectious fever onset and radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage. METHODS: We evaluated 44 patients for the association between noninfectious fever (greater than 101.5°F) and the development of radiographic vasospasm by digital subtraction angiography (DSA) and transcranial Doppler (TCD), DIND, DCI, and modified Rankin scale outcome score at 6 months to 2 years. Multivariate logistic regression analyses were performed to account for patient age, sex, admission Hunt and Hess grade, and Fisher grade. TCD was additionally used for temporal analysis. RESULTS: Noninfectious fever was significantly associated with radiographic vasospasm using both DSA (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.5; P = 0.02) and TCD (OR, 2.4; 95% CI, 1.2-5.6; P = 0.02), but it was not associated with DIND, DCI, or outcome. The maximum cross correlation between TCD velocity and temperature occurred for temperatures taken 1 day prior to TCD velocity measurement. A quadratic mixed-effects model demonstrated that TCD velocity was significantly associated with temperature from 1 day prior to TCD velocity measurement (ß = 13.5; 95% CI, 0.83-8.79, P = 0.01), posthemorrhage day (ß = 20.1; 95% CI, 2.14-7.52; P < 0.001), and (posthemorrhage day)2 (ß = -0.72; 95% CI, -0.26 to -0.11; P < 0.001). CONCLUSIONS: Noninfectious fever was associated with the development of radiographic vasospasm but not with DIND, DCI, or clinical outcome. Furthermore, there is a temporal association between the onset of noninfectious fever and radiographic vasospasm by 1 day. Fever independent of patient's infectious profile may be an early marker for the development of radiographic vasospasm.


Assuntos
Febre/diagnóstico por imagem , Febre/terapia , Hemorragia Subaracnóidea/diagnóstico por imagem , Hemorragia Subaracnóidea/terapia , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/terapia , Idoso , Feminino , Febre/epidemiologia , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Hemorragia Subaracnóidea/epidemiologia , Resultado do Tratamento , Vasoespasmo Intracraniano/epidemiologia
12.
J Stroke Cerebrovasc Dis ; 27(11): 3043-3045, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30087075

RESUMO

Reversible cerebral vasoconstriction syndrome is characterized by thunderclap headache and multifocal cerebral vasoconstriction. Cerebral vasoconstriction is reversible, and most cases have good prognosis. However, clinical outcome is possibly severe when it is complicated by stroke, yet detailed reports on such a case are few. We experienced a case of severe reversible cerebral vasoconstriction syndrome in a 32-year-old woman with medical history of preeclampsia 3years prior. She presented with sudden sharp headache followed by altered mental status and vasoconstriction of the bilateral posterior cerebral arteries. She was treated with intravenous and oral calcium channel blockers, edaravone, and glycerol. However, the cerebral infarction in the posterior circulation subsequently remained, and her impaired consciousness did not recover. Furthermore, although imaging findings of vasoconstriction showed improvement a day after the occurrence of symptom, the same vessels showed poor visualization 7 weeks later, which indicated the recurrence of vasoconstriction, without additional symptom due to the fixed infarction. Although most cases of reversible cerebral vasoconstriction syndrome show good prognosis, neurologists must monitor the possibility of worse clinical course and permanent neurological deficit when associated with stroke, such as cerebral infarction. Strict management and treatment are needed in these cases.


Assuntos
Infarto da Artéria Cerebral Posterior/etiologia , Artéria Cerebral Posterior/fisiopatologia , Vasoconstrição , Vasoespasmo Intracraniano/complicações , Adulto , Angiografia Cerebral/métodos , Imagem de Difusão por Ressonância Magnética , Feminino , Transtornos da Cefaleia Primários/etiologia , Transtornos da Cefaleia Primários/fisiopatologia , Humanos , Infarto da Artéria Cerebral Posterior/diagnóstico por imagem , Infarto da Artéria Cerebral Posterior/fisiopatologia , Infarto da Artéria Cerebral Posterior/terapia , Angiografia por Ressonância Magnética , Artéria Cerebral Posterior/diagnóstico por imagem , Síndrome , Tomografia Computadorizada por Raios X , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/fisiopatologia , Vasoespasmo Intracraniano/terapia
13.
Rinsho Shinkeigaku ; 58(6): 377-384, 2018 Jun 27.
Artigo em Japonês | MEDLINE | ID: mdl-29863100

RESUMO

This study reports eleven cases of reversible cerebral vasospasm syndrome (RCVS). Of the 11 patients, two were males and nine were females, with the average age of 47.9 ± 14.1 years. Many of these patients were young. The rates of severe, intractable and pulsative headache, generalized convulsions, and motor hemiparesis were 64%, 27%, and 36%, respectively. As complications of intracerebral lesions in the early stage of disease onset, convexal subarachnoid hemorrhage, lobar intracerebral hemorrhage, and posterior reversible encephalopathy syndrome were observed in 63%, 9%, and 45% of cases, respectively. Cerebral infarction occurred in 45% of cases at around 1-3 weeks after onset. Improvement of cerebral vasoconstriction was recognized in several cases from about the first month of onset. The post-partum period, migraine, transfusion, rapid amelioration for anemia, renal failure, bathing, and cerebrovascular dissection were suspected as disease triggers. Abnormally high blood pressure at onset was confirmed in 55% of cases. It is important to analyze the pathophysiology of RCVS associated with these triggers from the viewpoint of the breakdown of the blood-brain barrier.


Assuntos
Hemorragia Cerebral , Infarto Cerebral , Cefaleia , Vasoespasmo Intracraniano , Adulto , Idoso , Hemorragia Cerebral/diagnóstico por imagem , Hemorragia Cerebral/etiologia , Hemorragia Cerebral/terapia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Infarto Cerebral/terapia , Feminino , Cefaleia/diagnóstico por imagem , Cefaleia/etiologia , Cefaleia/terapia , Humanos , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Síndrome , Vasoconstrição , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/terapia
14.
World Neurosurg ; 116: e452-e459, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29753899

RESUMO

BACKGROUND: Vasospasm is a major cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage. Early treatment of ruptured aneurysms is advocated; delayed intervention complicates the treatment strategy leading to significant vasospasm and poor prognosis. We report an endovascular protocol for occlusion of the unsecured aneurysm and angioplasty for vasospasm in a single session. METHODS: Between January 2011 and May 2017, among 660 patients with aneurysmal subarachnoid hemorrhage, 24 patients with significant vasospasm and unsecured ruptured cerebral aneurysm were reviewed. Continuous nimodipine drip through a pressure line of the guiding catheter was set up. Aggressive angioplasty with a compliant balloon catheter either before or after embolization of the aneurysm in the major branches of vasospastic territory was performed. The goal was complete embolization of the aneurysm. RESULTS: Of 24 patients, 17 had ischemic symptoms at presentation, and the average delay from aneurysm rupture to presentation was 7.58 days. Angioplasty and nimodipine drip were performed on all patients. Severity of vasospasm was significantly reduced, and outcome improved in each patient. Two patients required a second angioplasty. In 20 patients, embolization of aneurysms was achieved without any aneurysmal sac or residual neck. Clinical outcome was good recovery (modified Rankin Scale score 0-2) in 23 patients (95.8%) and moderate disability in 1 patient (modified Rankin Scale score 3). CONCLUSIONS: Aggressive endovascular treatment of patients with unsecured ruptured cerebral aneurysm and associated vasospasm is safe and effective.


Assuntos
Aneurisma Roto/terapia , Angioplastia/métodos , Embolização Terapêutica/métodos , Aneurisma Intracraniano/terapia , Nimodipina/administração & dosagem , Vasoespasmo Intracraniano/terapia , Adulto , Idoso , Aneurisma Roto/diagnóstico por imagem , Aneurisma Roto/epidemiologia , Terapia Combinada , Feminino , Humanos , Injeções Intra-Arteriais , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Vasodilatadores/administração & dosagem , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/epidemiologia
15.
World Neurosurg ; 115: 341-345, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29751188

RESUMO

BACKGROUND: Reversible cerebral vasoconstriction syndrome (RCVS) is a rare entity with an unknown pathophysiology. RCVS has been reported to occur more frequently in women age 20-50 years. Several causative mechanisms have been postulated involving transient deregulation of cerebral arterial tone, small vessel endothelial dysfunction, biochemical factors, hormonal deregulation, oxidative stress, and genetic predisposition. All these mechanisms and triggers are related to sympathetic overactivation, which eventually produces vasoconstriction. RCVS is distinguished by acute severe recurrent thunderclap headaches with or without other neurologic symptoms. However, the diagnosis can be challenging, requiring a high level of suspicion by the clinician, and RCVS is often underdiagnosed. CASE DESCRIPTION: We present an unusual case of an 18-year-old female who developed RCVS after embolization of a dural arteriovenous fistula with onyx embolic material. Cerebral angiography was performed and verapamil was administered intra-arterially, resulting in a slight decrease in vasoconstriction with clinical improvement. The patient was maintained on oral verapamil during hospitalization. At a 7-month follow-up, the patient was neurologically stable, and cerebral angiography demonstrated no signs of vasoconstriction. CONCLUSIONS: Endovascular procedures are a rare trigger for the development of RCVS and may be misdiagnosed. Prompt recognition of symptoms and diagnosis with treatment are necessary to reduce the risk of stroke. The management approach should be based on the premise of discontinuing precipitating drugs and administering calcium channel blocking agents.


Assuntos
Malformações Vasculares do Sistema Nervoso Central/terapia , Dimetil Sulfóxido/administração & dosagem , Embolização Terapêutica/métodos , Polivinil/administração & dosagem , Vasoconstrição/fisiologia , Vasoespasmo Intracraniano/terapia , Adolescente , Malformações Vasculares do Sistema Nervoso Central/complicações , Malformações Vasculares do Sistema Nervoso Central/diagnóstico por imagem , Feminino , Humanos , Síndrome , Vasoconstrição/efeitos dos fármacos , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologia
16.
J Neurol Sci ; 390: 44-51, 2018 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-29801906

RESUMO

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is an important cause of further morbidity and mortality after an already devastating condition. Though traditionally attributed to vasospasm of large capacitance arteries and the resulting down-stream disruption of cerebral blood flow, the pathogenesis of DCI has proven to be more complex with early brain injury, blood-brain barrier disruption, microthrombosis, cortical spreading depolarizations, and the failure of cerebral autoregulation as newly elucidated factors. Vasospasm is a known consequence of SAH. The standard of care includes close monitoring for neurological deterioration, most often with serial clinical examinations, transcranial Doppler ultrasonography, and vascular imaging (crucial for early detection of DCI and allows for prompt intervention). Nimodipine continues to remain an important pharmacological strategy to improve functional outcomes in patients with SAH at risk for developing vasospasm. The paradigm for first line therapy in patients with vasospasm of induced hypertension, hypervolemia, and hemodilution has recently been challenged. Current American Heart Association guidelines recommend targeting euvolemia and judicious use of the pharmacologically induced hypertension component. Symptomatic vasospasm patients who do not improve with this first line therapy require rescue intervention with mechanical or chemical angioplasty and optimization of cardiac output and hemoglobin levels. This can be escalated in a step-wise fashion to include adjunct treatments such as intrathecal administration of vasodilators and sympatholytic or thrombolytic therapies. This review provides a general overview of the treatment modalities for DCI with a focus on novel management strategies that show promising results for treating vasospasm to prevent DCI.


Assuntos
Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/terapia , Resistência a Medicamentos , Humanos , Hemorragia Subaracnóidea/terapia
17.
Neuropediatrics ; 49(3): 213-216, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29523004

RESUMO

Despite the availability of modern antibiotics, pneumococcal meningitis in both children and adults remains a severe disease-one known to frequently cause grave complications and residual disability. Although the appearance of arterial vasospasms in bacterial meningitis systematically has been investigated and reported on for adult patients, such research is lacking when it comes to infants. We report on a 4-week-old infant who, 6 days after onset of pneumococcal meningitis, suffered severe neurological deterioration with treatment-resistant seizures and coma. Generalized cortical and subcortical edema developed in conjunction with diminished cerebral blood flow, as depicted in magnetic resonance angiography and serial Doppler-sonographic examinations. The ischemia resulted in extensive cystic encephalomalacia. We propose that the degree of variation in cerebral blood flow in the acute phase was the result of an extensive arterial vasculopathy involving vasospasms. Awareness of this complication and prospective serial Doppler-sonographic examinations may improve our understanding of the connection between brain edema and vasculopathy. At present, however, no effective treatment appears available.


Assuntos
Encefalomalacia/etiologia , Meningite Pneumocócica/complicações , Vasoespasmo Intracraniano/complicações , Encéfalo/diagnóstico por imagem , Encefalomalacia/diagnóstico por imagem , Encefalomalacia/terapia , Feminino , Humanos , Lactente , Meningite Pneumocócica/diagnóstico por imagem , Meningite Pneumocócica/terapia , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/terapia
18.
Neurol India ; 66(2): 416-422, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29547164

RESUMO

Background: The conventional medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is associated with uncertainty of outcome and complications. Aims and Objectives: To examine the effect of direct intra-arterial nimodipine therapy on outcome in patients with delayed cerebral ischemia (DCI). Settings and Design: The retrospective observational study was conducted at a single neurosurgical unit and interventional neuroradiolgy suite of a center managing SAH. Materials and Methods: Data analysis of SAH managed surgically during the period from January 2014 through October 2015 was performed. Any decline in the neurological status on clinical examination, such as consciousness, motor and speech deficits, without other identifiable causes such as hydrocephalus, hyponatremia, seizure, intracranial hematoma, or infection, was used to define the presence of DCI. Patients with suspected DCI underwent computed tomography (CT) scan of the head followed by angiography. When vasospasm was detected in the absence of any major arterial territory infarct, the patients were managed with intra-arterial nimodipine therapy. The outcome at discharge was assessed. Statistical Analysis: Mid-P exact, two-tailed P value was used for categorical variables. Results:: A total of 106 patients underwent surgical clipping of an aneurysm following SAH. DCI was diagnosed in 26 (24.5%) patients. Twenty three (88.5%) patients underwent intra-arterial nimodipine therapy. Angiographic response was seen in 22 (95.7%) patients and clinical response in 20 (87%) patients. At discharge, 19 patients (73.1%) with vasospasm had a favorable outcome. There was no significant difference in the outcome of patients with or without vasospasm. Conclusions: Aggressive management with intra-arterial nimodipine therapy is effective in preventing disability caused by DCI.


Assuntos
Gerenciamento Clínico , Infusões Intra-Arteriais/métodos , Nimodipina/uso terapêutico , Vasodilatadores/uso terapêutico , Vasoespasmo Intracraniano/terapia , Adolescente , Adulto , Idoso , Angiografia Digital , Criança , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/etiologia , Estudos Retrospectivos , Hemorragia Subaracnóidea/complicações , Tomógrafos Computadorizados , Vasoespasmo Intracraniano/etiologia , Adulto Jovem
19.
Zhongguo Zhen Jiu ; 38(2): 137-42, 2018 Feb 12.
Artigo em Chinês | MEDLINE | ID: mdl-29473355

RESUMO

OBJECTIVE: To evaluate the effect and clinical value of auricular point sticking for the diagnosis and treatment of vasospasm and vagus reflex during radial artery puncture, including radial artery spasm (RAS) and coronary artery spasm (CAS). METHODS: A total of 480 patients were randomized into an observation group (224 cases) and a control group (256 cases). Percutaneous coronary intervention and usual care in perioperative period were used in the control group. Auricular point sticking was began to apply 12 h before percutaneous coronary intervention in the observation group at Jiaogan (AH6a), Shenmen (TF4), Pizhixia (AT4), Neifenmi (CO18), Xin (CO15), Shen (CO10), Shenshangxian (TG2p), 1 min a time every point, once every 2 h, 12 h before and after operation. The incidences of vasospasm and vagus reflex during piercing process were compared, and the usage ratios of vasoactive agent were recorded, including glyceryl trinitrate, dopamine and atropine injections. RESULTS: The incidence of angiospasm was 4.9% (11/224) in the observation group, which was lower than 13.3% (34/256) in the control group (P<0.01). The incidence of vagal reflex of the observation group was 7.1% (16/224), which was lower than 19.5% (50/256) of the control group (P<0.01). The usage ratios of glyceryl trinitrate, atropine and dopamine injections were 3.6% (8/224), 7.1% (16/224), 6.3% (14/224) respectively in the observation group, which were lower than 14.8% (38/256), 15.6% (40/256), 15.2% (39/256) in the control group (all P<0.01). . CONCLUSION: Auricular point sticking achieves effect for the diagnosis and treatment of vasospasm and vagus reflex during radial artery puncture.


Assuntos
Acupuntura Auricular , Artéria Radial/lesões , Vasoespasmo Intracraniano/terapia , Pontos de Acupuntura , Humanos , Punções , Reflexo , Nervo Vago
20.
Br J Neurosurg ; 32(2): 157-164, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29338431

RESUMO

PURPOSE: Arterial vasospasm is a major cause of death and long-term disability following subarachnoid haemorrhage (SAH). The use of medically induced hypertension, hypervolaemia and/or haemodilution is widely practiced for prophylaxis and treatment of vasospasm following SAH. We aimed to determine if the quality of available research is adequate to inform use of haemodynamic management strategies to prevent or treat vasospasm following SAH. METHODS: Individual searches of the following databases were conducted: The Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and OpenSIGLE. Pertinent randomised clinical trials and cohort studies comparing any element or combination thereof: medically induced hypertension, hypervolaemia, and haemodilution were included. Data were extracted using standardised proformas and risk of bias assessed using a domain-based risk of bias assessment tool. RESULTS: 348 study reports were identified by our literature search. Eight studies were included, three of which examined both volume expansion and medically induced hypertension. Three randomised clinical trials and two cohort studies examining prophylactic volume expansion were included. Two trials of prophylactic medically induced hypertension and two cohort studies were included. One trial and one cohort study of medically induced hypertension for treatment of established vasospasm was included. These trials demonstrated no significant difference in any of the clinical outcome measures studied. No trials of blood transfusion were included. CONCLUSIONS: There is currently insufficient evidence to determine the efficacy or non-efficacy of intravenous volume expansion, medically induced hypertension or blood transfusion for the treatment or prophylaxis of vasospasm following SAH. All of these approaches have been associated with adverse events, of unclear incidence. The current evidence base therefore cannot be used to reliably inform clinical practice. This is a priority for further research.


Assuntos
Volume Sanguíneo , Hemodiluição/métodos , Hipertensão , Hemorragia Subaracnóidea/terapia , Vasoespasmo Intracraniano/terapia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/etiologia
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