Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage
Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage
Medical therapies for PHCV are endorsed by the Stroke Council of the AHA as a Class IIa recommendation, Level of Evidence B. These therapies focus on augmentation of cerebral perfusion through an increase in mean arterial pressure and central venous pressures by intravascular volume expansion and intravenous administration of vasopressors. Additional hemodynamic therapies focused on increasing preload and decreasing blood viscosity have been described. Specific recommendations for the medical management of PHCV were summarized in a recent consensus report from the Neurocritical Care Society. In many patients, medical therapy will restore a compensated state of cerebral perfusion and reverse associated neurological deficits. Medical therapy is generally considered firstline management for PHCV as the treatment related risks are usually much lower than the risks of invasive interventional therapies. Exceptions may include PHCV in patients with unsecured ruptured aneurysms and patients with decompensated cardiac disease or intestinal ischemia. Although there is a significant risk of aneurysm rebleeding in patients with unsecured ruptured aneurysms, hypertensive therapy has not been associated with bleeding from unruptured aneurysms in SAH patients that have multiple aneurysms. Patients with extensive myocardial infarction, decompensated heart failure or other cardiac disease may not tolerate aggressive medical therapy. Medical therapy may also be limited by specific complications, including intestinal ischemia.
Medical Management
Medical therapies for PHCV are endorsed by the Stroke Council of the AHA as a Class IIa recommendation, Level of Evidence B. These therapies focus on augmentation of cerebral perfusion through an increase in mean arterial pressure and central venous pressures by intravascular volume expansion and intravenous administration of vasopressors. Additional hemodynamic therapies focused on increasing preload and decreasing blood viscosity have been described. Specific recommendations for the medical management of PHCV were summarized in a recent consensus report from the Neurocritical Care Society. In many patients, medical therapy will restore a compensated state of cerebral perfusion and reverse associated neurological deficits. Medical therapy is generally considered firstline management for PHCV as the treatment related risks are usually much lower than the risks of invasive interventional therapies. Exceptions may include PHCV in patients with unsecured ruptured aneurysms and patients with decompensated cardiac disease or intestinal ischemia. Although there is a significant risk of aneurysm rebleeding in patients with unsecured ruptured aneurysms, hypertensive therapy has not been associated with bleeding from unruptured aneurysms in SAH patients that have multiple aneurysms. Patients with extensive myocardial infarction, decompensated heart failure or other cardiac disease may not tolerate aggressive medical therapy. Medical therapy may also be limited by specific complications, including intestinal ischemia.
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