When cerebral vasospasm after subarachnoid hemorrhage begins and ends? Definition of vasospasm using angiography

Cerebral vasospasm (VS) after subarachnoid hemorrhage (SAH) is one of the fatal strokes causing severe brain ischemia. So far, many types of treatments for VS have been applied, such as triple H therapy, clot fibrinolysis, spinal drainage, endovascular treatment, or administration of vasodilatory agents, but its pathophysiology has been still unknown, and absolute therapeutic strategies have not been established yet. One of the reasons why the strategies of VS treatment has not been confirmed is that clear definition of VS has not given until now. For instance, there are many cases which have no symptoms while these patients have obvious angiographic VS, or it is difficult to distinguish between real VS symptoms and neurological deterioration due to fever, abnormal blood levels of electrolytes, primary brain damages from SAH. Therefore, incidence of VS and the timing of its treatment are sometimes different among each facility. From 2000, we define VS as angiographic VS in our institute. When symptomatic VS is suspected clinically, emergency angiography is immediately performed and confirm VS. And then if necessary, endovascular therapy is given. Even if there are no VS symptoms during spasm periods, we routinely perform angiography on around day 7 as shown in the following protocol (see table). Under this protocol, angiographic VS was seen in 59.7% of the 57 patients, while, symptomatic VS was seen in 37.1%. In this study, we discuss the advantages of this definition of VS by angiography. Table: A. Treatment after surgery 1) Drains(always inserted) Ventricular drainage (VD) + cisternal (CD) or lumber drainage (LD) 2) Fibrinolysis UK 30,000IU/day, injected through VD Repeated if necessary by Day 4 3) General management(under strict control) Normo-hypertension, normovolemia (≧120mmHg, CVP≒8-10) Hct(≦9.0mg/dl), ICP(≧20mmH2O),and electrolytes(≧130meq/L) Ozagrel Na (i.v.) Fasudil (i.v.) 4) Intravascular treatment (if severe angiographic VS was detected.) Fasudil (i.a.) Percutaneous transluminal angioplasty (PTA) B. Detection of VS 1) TCD monitor 2) Neurological changes 3) Angiography When TCD or neurological changes are detected On day 7 (routine exam.) 4) INVOS5100R(Somanetics, USA): 2005∼ Near infrared spectroscopy, measuring rSO2.