Department of Neurology, University of Alabama School of Medicine, 1720 2nd Ave, S. FOT 1203, Birmingham, AL 35294-3412, USAUnited States
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Vasospasm almost always occurs following rupture of an aneurysm in the Circle of Willis. Spasm is less likely in peripherally located aneurysms, for example those complicating bacterial endocarditis. For a day or two spasm is often absent or minimal. If the patient’s condition is good, many surgeons will proceed at this time either with surgery or endovascular placement of coils in the aneurysm to make it undergo thrombosis.
Keywords: thrombosis; aneurysm; endovascular
NEURO ISSN 2377-1607 http://dx.doi.org/10.17140/NOJ-1-e001 Open Journal Editorial Vasospasm Monitored by Transcranial * *Corresponding author Doppler James H. Halsey, MD Professor Emeritus Department of Neurology * James H. Halsey University of Alabama School of Medicine nd 1720 2nd Ave, S. FOT 1203 Department of Neurology, University of Alabama School of Medicine, 1720 2nd Ave, S. FOT Birmingham, AL 35294-3412, USA 1203, Birmingham, AL 35294-3412, USA Tel. (205)592-2177 E-mail: jhhalsey@gmail.com Vasospasm almost always occurs following rupture of an aneurysm in the Circle of Volume 1 : Issue 1 Willis. Spasm is less likely in peripherally located aneurysms, for example those complicating Article Ref. #: 1000NOJ1e001 bacterial endocarditis.
For a day or two spasm is often absent or minimal. If the patient’s condition is good, Article History th many surgeons will proceed at this time either with surgery or endovascular placement of coils Received: October 11 , 2014 th in the aneurysm to make it undergo thrombosis.
Accepted: November 8 , 2014 th Published: November 10th, 2014 Spasm is due to the evolution of oxyhemoglobin from hemoglobin, causing deple- tion of the vasodilating nitrous oxide synthase.1 From the third day after hemorrhage onward, Citation with or without surgical or endovascular intervention, spasm develops progressively, generally Halsey JH. Vasospasm moni- reaching a maximum plateau at the end of the first week. It is during the period of increasing tored by transcranial doppler.
spasm and the early plateau period that serious ischemic complications are likely to occur.The Neuro Open J. 2014; 1(1): e1.
standard management during this time is “Triple H”: Hypertension, Hemodilution, and Hyper- doi: 10.17140/NOJ-1-e001 volemia.
Although this paradigm has been widely accepted for 20 years its efficacy remains unproven. Moreover it may carry medical morbidity, including pulmonary edema, myocardial ischemia, catheter infections, and cerebral edema.2 Obviously careful ICU monitoring of the potential medical morbidities is important.
For specific monitoring, we have adopted the technique of Transcranial Doppler (TCD).3 This non-invasive method permits daily measurements defining the severity and time course of the evolving spasm in the individual patient. We have found that daily measurements are essential for this purpose. This enables optimization of medical management of the medical therapy.
In most cases this is adequate to bring the patient through without ischemic damage. In rare cases, TCD demonstrates a rapidly increasing severity of spasm. This is usually confirmed by angiography representing a vascular emergency. This can be dealt with by percutaneous angioplasty As the plateau progresses after which spasm decreases. All this can be objectively defined by TCD.