With respect to the management of patients with aneursymal sub arachnoid haemorrhage (aSAH), briefly discuss the role of the following:
Level I evidence of improved neurological outcome. Calcium antagonist. Likely prevents neuronal damage by preventing influx of Ca more than by antagonising Sm muscle contraction and directly reducing incidence of vasospasm. May lead to hypotension.
Meta-analyses suggest oral efficacious
IV expensive; needs co-infusion
Recommended for all patients with aneurysmal SAH
Triple H therapy:
Haemodilution – no good evidence that works in isolation. Theoretically improved rheology => better perfusion
Hypervolaemia – no evidence that hypervolaemia is beneficial and fluid overload associated with worse outcomes. Hypovolaemia should be avoided as may exacerbate vasospasm. Volume loading often given to patients with clinical vasospasm to ensure euvolaemia
Hypertensive therapy: Unsecured aneurysm a relative CI to HT therapy. Demonstrated to improve cerebral blood flow. Not useful for prevention of vasospasm, but commonly used to treat cerebral ischaemia in the presence of vasospasm. May be titrated to clinical response. NA favoured agent. Sometimes high doses of pressor agents required to augment MAP. Risk of stress cardiomyopathy. Unless titrated to clear neurological signs the optimal MAP goals are unclear. Balance of risks vs benefits.
Intra-arterial vasodilators: e.g. verapamil / papaverine / nicardipine. Clear angiographic benefit / used routinely for the treatment of vasospasm. Lacking high-level data on outcome benefit. Other angiographic interventions such as ballooning / stents are also utilised to good angiographic effect. Not routinely available in all centres. Caries the risks associated with angiography (transport, anaesthesia, contrast use, vascular injury, stroke)
Several trials of MgSO4 – these have failed to show benefit. Not routinely indicated for the prevention of vasospasm although low magnesium may be associated with its development.
The college question - though asking about therapeutic options which are mainly used to prevent or treat vasospasm - is actually not worded in a way which limits one's answer to only vasospasm. Therefore, some additional material could be added to the interventional radiology section, which deals more with its merits as a diagnostic modality.
"Triple H therapy"
Conventional 4 vessel DSA (Digital Subtraction Angiography):
Chapter 51 (pp. 568) Acute cerebrovascular complications by Bernard Riley and Thearina de Beer
LITFL offer this reference as a follow-on to their chapter:
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