Vasospasm

A brain vasospasm is a frequent and serious complication that occurs following a subarachnoid haemorrhage (SAH) due to the rupture of an intracranial aneurysm. It is characterised by a prolonged and severe narrowing of the brain arteries, thereby reducing the blood flow to the brain and possibly resulting in secondary strokes. 

Vasospasm symptoms can vary depending on the area of the brain affected and include:  

• Severe headaches
• Consciousness  problems
• Focal neurological deficits (paralysis, speech problems)
• Confusion, agitation
• Epileptic fits

These symptoms generally appear between the third and 14th day after the aneurysm rupture, the incidence peaking at around the seventh day.   

Imaging examinations

To detect and monitor a vasospasm a number of imaging methods are used:    

• Brain angiograph: regarded as the gold standard for detecting a vasospasm.
• CT scan  with angiograph (CTA) and perfusion : useful for visualising  the brain arteries and the impact on the arrival of blood in the brain  
• Magnetic Resonance Imaging (MRI) with angiograph (MRA): non-invasive alternative that is a more complex procedure to carry out in an emergency.
• Transcranial Doppler (TCD) ultrasound: non-invasive method that makes it possible to measure the rate of the blood flow  to the brain arteries, indicative of a vasospasm.  

Medical pathway

Patients having suffered a vasospasm are generally treated at a specialised hospital, in particular in neurosurgery or interventional neuroradiology. The pathway includes the intervention of :  

• Emergency staff: first to intervene following the rupture of an aneurysm.
• Neurosurgeons: for initial management of the aneurysm and complications.
• Interventional neuroradiologists: for diagnosis and treatment with embolization of the aneurysm.
• Neurologists: for follow up and management of neurological complications.

Treatment

Treatment options for a vasospasm include:    

• Medicinal treatment: administration of calcium channel blockers (nimodipine) to prevent  vasospasms. A high level of evidence for prevention but limited for treatment.  
• Endovascular treatment: balloon angioplasty, stents or intra-arterial administration of vasodilators  (nimodipine, papaverine, milrinone). These treatments show a variable effectiveness depending on the studies and are often used in the case of severe and refractory vasospasm.  
• Haemodynamic treatment: increase in blood pressure and in the intravascular blood pressure to improve the blood flow to the brain. Evidence of its effectiveness is debatable.  

Multidisciplinary discussion

Vasospasm treatment requires a multidisciplinary approach involving regular meetings of neurosurgeons, neuroradiologists, neurologists and critical care medicine specialists to discuss complex cases and adapt treatment strategies.  

Follow up

Ongoing monitoring of patients having experienced a post-stroke vasospasm is crucial. This includes:    

• Regular neurological follow up: to detect and manage neurological  sequels.
• Rehabilitation: to help patients  recover lost functions.
• Imaging: to monitor the condition of the blood vessels in the brain and detect any relapses.  
• Risk factor management: blood pressure checks, stopping smoking, etc. to prevent future strokes.

Follow up must be carried out by a multidisciplinary team to optimise the long term results of patients