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01-02-2009 | Practical Pearl

Posttraumatic Vasospasm Detected by Continuous Brain Tissue Oxygen Monitoring: Treatment with Intraarterial Verapamil and Balloon Angioplasty

Authors: Kiarash Shahlaie, James E. Boggan, Richard E. Latchaw, Cheng Ji, J. Paul Muizelaar

Published in: Neurocritical Care | Issue 1/2009

Abstract

Introduction

Posttraumatic vasospasm (PTV) is a relatively common event following traumatic brain injury (TBI) that has been strongly correlated with worse neurological outcome in many studies. However, vasospasm continues to be an under-recognized source of secondary injury following TBI, and currently published guidelines do not address screening or management strategies for PTV. Brain tissue oxygen (P_btO₂) monitoring probes allow for continuous screening for cerebral hypoxia following TBI, but their use as a monitor for PTV has not been previously described.

Methods

Case report and literature review.

Results

We present a case of PTV identified by persistent low P_btO₂ despite aggressive medical therapy. Computed tomography and digital subtraction angiography confirmed severe cerebral arterial vasospasm involving both anterior and posterior circulations. The patient was successfully treated with serial intraarterial therapy including balloon angioplasty and verapamil infusion.

Conclusion

Posttraumatic vasospasm should be included in the differential diagnosis of cerebral hypoxia (e.g., low P_btO₂) following TBI. Management strategies for PTV may include early, aggressive intraarterial therapies including drug infusion and balloon angioplasty.

Columnella F, Delzanno GB, Gaist G, Piazza G. Angiography in traumatic cerebral lacerations with special regard to some less common aspects. Acta Radiol Diagn (Stockh). 1963;1:239–47.

Frenidenfelt H, Sundctrom R. Local and general spasm in the internal carotid artery system following trauma. Acta Radiol. 1963;1:278–83.

Marshall LF, Bruce DA, Bruno L, Langfitt TW. Vertebrobasilar spasm: a significant cause of neurological deficit in head injury. J Neurosurg. 1978;48:560–4.PubMed

Wilkins RH, Odom GL. Intracranial arterial spasm associated with craniocerebral trauma. J Neurosurg. 1970;32:626–33.PubMed

Wilkins RH. Cerebral vasospasm in conditions other than subarachnoid hemorrhage. Neurosurg Clin N Am. 1990;1(2):329–34.PubMed

Suwanwela C, Suwanwela N. Intracranial arterial narrowing and spasm in acute head injury. J Neurosurg. 1972;36:314–23.PubMed

Vajramani GV, Chandramouli BA, Jayakumar PN, Kolluri S. Evaluation of posttraumatic vasospasm, hyperaemia, and autoregulation by transcranial colour-coded duplex sonography. Br J Neurosurg. 1999;13:468–73.PubMed

Hadani M, Bruk B, Ram Z, Knoller N, Bass A. Transiently increased basilar artery flow velocity following severe head injury: a time course transcranial Doppler study. J Neurotrauma. 1997;14:629–36.PubMed

Chan KH, Dearden NM, Miller JD. The significance of posttraumatic increase in cerebral blood flow velocity: a transcranial Doppler ultrasound study. Neurosurgery. 1992;30:697–700. doi:10.1097/00006123-199205000-00008.CrossRefPubMed

10.

Compton JS, Teddy PJ. Cerebral arterial vasospasm following severe head injury: a transcranial Doppler study. Br J Neurosurg. 1987;1:435–9. doi:10.3109/02688698708999633.CrossRefPubMed

11.

Martin NA, Doberstein C, Zane C, Caron MJ, Thomas K, Becker DP. Posttraumatic cerebral arterial spasm: transcranial Doppler ultrasound, cerebral blood flow, and angiographic findings. J Neurosurg. 1992;77:575–83.PubMed

12.

Weber M, Grolimund P, Seiler RW. Evaluation of posttraumatic cerebral blood flow velocities by transcranial Doppler ultrasonography. Neurosurgery. 1990;27:106–12. doi:10.1097/00006123-199007000-00015.CrossRefPubMed

13.

Zubkov AY, Pilkington AS, Bernanke DH, Parent AD, Zhang J. Posttraumatic cerebral vasospasm: clinical and morphological presentations. J Neurotrauma. 1999;16:763–70.PubMed

14.

Rozsa L, Gombi R, Szabo S, Sztermen M. Vasospasm after head injury studied by transcranial Doppler sonography. Radiol Diagn (Berl). 1989;30:151–7.

15.

Romner B, Bellner J, Kongstad P, Sjoholm H. Elevated transcranial Doppler flow velocities after severe head injury: cerebral vasospasm or hyperemia? J Neurosurg. 1996;85:90–7.PubMed

16.

Martin NA, Patwardhan RV, Alexander MJ, et al. Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm. J Neurosurg. 1997;87:9–19.PubMed

17.

Grolimund P, Weber M, Seiler RW, Reulen HJ. Time course of cerebral vasospasm after severe head injury. Lancet. 1988;1:1173. doi:10.1016/S0140-6736(88)91995-2.CrossRefPubMed

18.

Soustiel JF, Shik V. Posttraumatic basilar artery vasospasm. Surg Neurol. 2004;62:201–6; discussion 6. doi:10.1016/j.surneu.2003.10.037.

19.

Oertel M, Boscardin WJ, Obrist WD, et al. Posttraumatic vasospasm: the epidemiology, severity, and time course of an underestimated phenomenon: a prospective study performed in 299 patients. J Neurosurg. 2005;103:812–24.PubMed

20.

Soustiel JF, Shik V, Feinsod M. Basilar vasospasm following spontaneous and traumatic subarachnoid haemorrhage: clinical implications. Acta Neurochir (Wien). 2002;144:137–44; discussion 44. doi:10.1007/s007010200016.

21.

Armonda RA, Bell RS, Vo AH, et al. Wartime traumatic cerebral vasospasm: recent review of combat casualties. Neurosurgery. 2006;59:1215–25; discussion 25. doi:10.1227/01.NEU.0000249190.46033.94.

22.

Pasqualin A, Vivenza C, Rosta L, Licata C, Cavazzani P, Da Pian R. Cerebral vasospasm after head injury. Neurosurgery. 1984;15:855–8.PubMedCrossRef

23.

Kordestani RK, Martin NA, McBride DQ. Cerebral hemodynamic disturbances following penetrating craniocerebral injury and their influence on outcome. Neurosurg Clin N Am. 1995;6:657–67.PubMed

24.

Martin NA, Doberstein C, Alexander M, et al. Posttraumatic cerebral arterial spasm. J Neurotrauma. 1995;12:897–901.PubMed

25.

Lee JH, Martin NA, Alsina G, et al. Hemodynamically significant cerebral vasospasm and outcome after head injury: a prospective study. J Neurosurg. 1997;87:221–33.PubMed

26.

Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(Suppl 1):S1–106. doi:10.1089/neu.2006.0209.

27.

Chan KH, Dearden NM, Miller JD. Transcranial Doppler-sonography in severe head injury. Acta Neurochir Suppl (Wien). 1993;59:81–5.

28.

Chan KH, Dearden NM, Miller JD, Midgley S, Piper IR. Transcranial Doppler waveform differences in hyperemic and nonhyperemic patients after severe head injury. Surg Neurol. 1992;38:433–6. doi:10.1016/0090-3019(92)90111-Y.CrossRefPubMed

29.

European Study Group. A multicenter trial of the efficacy of nimodipine on outcome after severe head injury. The European Study Group on Nimodipine in Severe Head Injury. J Neurosurg. 1994;80:797–804.

30.

Ojha BK, Jha DK, Kale SS, Mehta VS. Trans-cranial Doppler in severe head injury: evaluation of pattern of changes in cerebral blood flow velocity and its impact on outcome. Surg Neurol. 2005;64:174–9; discussion 9. doi:10.1016/j.surneu.2004.11.030.

31.

Sander D, Klingelhofer J. Cerebral vasospasm following post-traumatic subarachnoid hemorrhage evaluated by transcranial Doppler ultrasonography. J Neurol Sci. 1993;119:1–7. doi:10.1016/0022-510X(93)90185-2.CrossRefPubMed

32.

Steiger HJ, Aaslid R, Stooss R, Seiler RW. Transcranial Doppler monitoring in head injury: relations between type of injury, flow velocities, vasoreactivity, and outcome. Neurosurgery 1994;34:79–85; discussion 85–6.

33.

Zurynski YA, Dorsch NW, Pearson I. Incidence and effects of increased cerebral blood flow velocity after severe head injury: a transcranial Doppler ultrasound study I. Prediction of post-traumatic vasospasm and hyperemia. J Neurol Sci. 1995;134:33–40. doi:10.1016/0022-510X(95)00172-9.CrossRefPubMed

34.

Arutiunov AI, Baron MA, Majorova NA. The role of mechanical factors in the pathogenesis of short-term and prolonged spasm of cerebral arteries. J Neurosurg. 1974;40:459–72.PubMed

35.

Echlin FA. Vasospasm and focal cerebral ischemia: an experimental study. Arch Neurol Psychiatry. 1942;47:77–96.

36.

Symon L. An experimental study of traumatic cerebral vascular spasm. J Neurol Neurosurg Psychiatry. 1967;30:497–505.CrossRefPubMed

37.

Arseni C, Maretsis M, Horvath L. Post-traumatic intracranial arterial spasm: report of three cases. Acta Neurochir (Wien). 1971;24:25–35. doi:10.1007/BF01403138.CrossRef

38.

Lewin W. Vascular lesions in head injuries. Br J Surg. 1968;55:321–31. doi:10.1002/bjs.1800550502.CrossRefPubMed

39.

Gaetani P, Rodriguez Y, Baena R, et al. Endothelin and aneurysmal subarachnoid haemorrhage: a study of subarachnoid cisternal cerebrospinal fluid. J Neurol Neurosurg Psychiatry. 1994;57:66–72.CrossRefPubMed

40.

Seifert V, Loffler BM, Zimmermann M, Roux S, Stolke D. Endothelin concentrations in patients with aneurysmal subarachnoid hemorrhage. Correlation with cerebral vasospasm, delayed ischemic neurological deficits, and volume of hematoma. J Neurosurg. 1995;82:55–62.PubMed

41.

Gomez CR, Backer RJ, Bucholz RD. Transcranial Doppler ultrasound following closed head injury: vasospasm or vasoparalysis? Surg Neurol. 1991;35:30–5. doi:10.1016/0090-3019(91)90198-I.CrossRefPubMed

42.

Zubkov AY, Lewis AI, Raila FA, Zhang J, Parent AD. Risk factors for the development of post-traumatic cerebral vasospasm. Surg Neurol. 2000;53:126–30. doi:10.1016/S0090-3019(99)00178-0.CrossRefPubMed

43.

Eisenberg HM, Gary HE Jr, Aldrich EF, et al. Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg. 1990;73:688–98.PubMed

44.

Mattioli C, Beretta L, Gerevini S, et al. Traumatic subarachnoid hemorrhage on the computerized tomography scan obtained at admission: a multicenter assessment of the accuracy of diagnosis and the potential impact on patient outcome. J Neurosurg. 2003;98:37–42.PubMed

45.

Morris GF, Bullock R, Marshall SB, Marmarou A, Maas A, Marshall LF. Failure of the competitive N-methyl-D-aspartate antagonist Selfotel (CGS 19755) in the treatment of severe head injury: results of two phase III clinical trials. The Selfotel Investigators. J Neurosurg. 1999;91:737–43.PubMed

46.

Kakarieka A, Braakman R, Schakel EH. Clinical significance of the finding of subarachnoid blood on CT scan after head injury. Acta Neurochir (Wien). 1994;129:1–5. doi:10.1007/BF01400864.CrossRef

47.

Kistler JP, Crowell RM, Davis KR, et al. The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study. Neurology. 1983;33:424–36.PubMed

48.

Taneda M, Kataoka K, Akai F, Asai T, Sakata I. Traumatic subarachnoid hemorrhage as a predictable indicator of delayed ischemic symptoms. J Neurosurg. 1996;84:762–8.PubMed

49.

Harders AG, Gilsbach JM. Time course of blood velocity changes related to vasospasm in the circle of Willis measured by transcranial Doppler ultrasound. J Neurosurg. 1987;66:718–28.PubMedCrossRef

50.

Weir B, Grace M, Hansen J, Rothberg C. Time course of vasospasm in man. J Neurosurg. 1978;48:173–8.PubMed

51.

Bakshi A, Mahapatra AK. Basilar artery vasospasm after severe head injury: a preliminary transcranial Doppler ultrasound study. Natl Med J India. 1998;11:220–1.PubMed

52.

Zurynski YA, Dorsch NW, Fearnside MR. Incidence and effects of increased cerebral blood flow velocity after severe head injury: a transcranial Doppler ultrasound study II. Effect of vasospasm and hyperemia on outcome. J Neurol Sci. 1995;134:41–6. doi:10.1016/0022-510X(95)00178-X.CrossRefPubMed

53.

Muttaqin Z, Arita K, Uozumi T, et al. Vasospasm after traumatic subarachnoid haemorrhage: transcranial Doppler evaluation. Case report. Neurosurg Rev. 1991;14:321–5. doi:10.1007/BF00383273.CrossRefPubMed

54.

Lindegaard KF, Nornes H, Bakke SJ, Sorteberg W, Nakstad P. Cerebral vasospasm diagnosis by means of angiography and blood velocity measurements. Acta Neurochir (Wien). 1989;100:12–24. doi:10.1007/BF01405268.CrossRef

55.

Jakobsen M, Enevoldsen E, Dalager T. Spasm index in subarachnoid haemorrhage: consequences of vasospasm upon cerebral blood flow and oxygen extraction. Acta Neurol Scand. 1990;82:311–20.PubMed

56.

Soustiel JF, Shik V, Shreiber R, Tavor Y, Goldsher D. Basilar vasospasm diagnosis: investigation of a modified “Lindegaard Index” based on imaging studies and blood velocity measurements of the basilar artery. Stroke. 2002;33:72–7. doi:10.1161/hs0102.100484.CrossRefPubMed

57.

Sarrafzadeh AS, Sakowitz OW, Kiening KL, Benndorf G, Lanksch WR, Unterberg AW. Bedside microdialysis: a tool to monitor cerebral metabolism in subarachnoid hemorrhage patients? Crit Care Med. 2002;30:1062–70. doi:10.1097/00003246-200205000-00018.CrossRefPubMed

58.

Vajkoczy P, Horn P, Thome C, Munch E, Schmiedek P. Regional cerebral blood flow monitoring in the diagnosis of delayed ischemia following aneurysmal subarachnoid hemorrhage. J Neurosurg. 2003;98:1227–34.PubMed

59.

Meixensberger J, Vath A, Jaeger M, Kunze E, Dings J, Roosen K. Monitoring of brain tissue oxygenation following severe subarachnoid hemorrhage. Neurol Res. 2003;25:445–50. doi:10.1179/016164103101201823.CrossRefPubMed

60.

Vath A, Kunze E, Roosen K, Meixensberger J. Therapeutic aspects of brain tissue pO₂ monitoring after subarachnoid hemorrhage. Acta Neurochir Suppl (Wien). 2002;81:307–9.

61.

Muench E, Horn P, Bauhuf C, et al. Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. 2007;35:1844–51; quiz 52. doi:10.1097/01.CCM.0000275392.08410.DD.

62.

Hoelper BM, Hofmann E, Sporleder R, Soldner F, Behr R. Transluminal balloon angioplasty improves brain tissue oxygenation and metabolism in severe vasospasm after aneurysmal subarachnoid hemorrhage: case report. Neurosurgery. 2003;52:970–4; discussion 4–6. doi:10.1227/01.NEU.0000053033.98317.A3.

63.

Wilensky EM, Bloom S, Leichter D, et al. Brain tissue oxygen practice guidelines using the LICOX CMP monitoring system. J Neurosci Nurs. 2005;37:278–88.PubMed

64.

Doppenberg EM, Zauner A, Watson JC, Bullock R. Determination of the ischemic threshold for brain oxygen tension. Acta Neurochir Suppl (Wien). 1998;71:166–9.

65.

Doppenberg EMR, Zauner A, Bullock R, Ward JD, Fatouros PP, Young HF. Correlations between brain tissue oxygen tension, carbon dioxide tension, pH, and cerebral blood flow—a better way of monitoring severely injured brain? Surg Neurol. 1998;49:650–4. doi:10.1016/S0090-3019(97)00355-8.CrossRefPubMed

66.

Stiefel MF, Udoetuk JD, Spiotta AM, et al. Conventional neurocritical care and cerebral oxygenation after traumatic brain injury. J Neurosurg. 2006;105:568–75. doi:10.3171/jns.2006.105.4.568.CrossRefPubMed

67.

Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. X. Brain oxygen monitoring and thresholds. J Neurotrauma. 2007;24(1):S65–70.

68.

Rosenthal G, Hemphill JCIII, Sorani M, et al. Brain tissue oxygen tension is more indicative of oxygen diffusion than oxygen delivery and metabolism in patients with traumatic brain injury. Crit Care Med. 2008;36:1917–24. doi:10.1097/CCM.0b013e3181743d77.CrossRefPubMed

69.

Macpherson P, Graham DI. Arterial spasm and slowing of the cerebral circulation in the ischaemia of head injury. J Neurol Neurosurg Psychiatry. 1973;36:1069–72.CrossRefPubMed

70.

Macpherson P, Graham DI. Correlation between angiographic findings and the ischaemia of head injury. J Neurol Neurosurg Psychiatry. 1978;41:122–7.CrossRefPubMed

71.

Kochanowicz J, Krejza J, Mariak Z, Bilello M, Lyson T, Lewko J. Detection and monitoring of cerebral hemodynamic disturbances with transcranial color-coded duplex sonography in patients after head injury. Neuroradiology. 2006;48:31–6. doi:10.1007/s00234-005-0009-4.CrossRefPubMed

72.

Lee KH, Lukovits T, Friedman JA. “Triple-H” therapy for cerebral vasospasm following subarachnoid hemorrhage. Neurocrit Care. 2006;4:68–76. doi:10.1385/NCC:4:1:068.CrossRefPubMed

73.

Yamada K, Harada M, Hasegawa S, Ushio Y. Delayed posttraumatic middle cerebral artery vasospasm demonstrated by magnetic resonance angiography: case report. Neurosurgery. 1998;43:153–6. doi:10.1097/00006123-199807000-00101.CrossRefPubMed

74.

Robertson CS, Valadka AB, Hannay HJ, et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med. 1999;27:2086–95. doi:10.1097/00003246-199910000-00002.CrossRefPubMed

75.

Dorhout Mees SM, Rinkel GJ, Feigin VL, et al. Calcium antagonists for aneurysmal subarachnoid hemorrhage. Stroke. 2008;39(2):514–5.CrossRef

76.

Bailey I, Bell A, Gray J, et al. A trial of the effect of nimodipine on outcome after head injury. Acta Neurochir (Wien). 1991;110:97–105. doi:10.1007/BF01400674.CrossRef

77.

Teasdale G, Bailey I, Bell A, et al. The effect of nimodipine on outcome after head injury: a prospective randomised control trial. The British/Finnish Co-operative Head Injury Trial Group. Acta Neurochir Suppl (Wien). 1990;51:315–6.

78.

Harders A, Kakarieka A, Braakman R. Traumatic subarachnoid hemorrhage and its treatment with nimodipine. German tSAH Study Group. J Neurosurg. 1996;85:82–9.PubMed

79.

Xiao X, Guo X, Wang D, Xue G. Mechanism and treatment principle for cerebral vessel spasm caused by concussion. Chin J Traumatol. 2002;5:380–4.PubMed

80.

Kostron H, Rumpl E, Stampfl G, Russegger L, Grunert V. Treatment of cerebral vasospasm following severe head injury with the calcium influx blocker nimodipine. Neurochirurgia (Stuttg). 1985;28(Suppl 1):103–9.

81.

Kostron H, Twerdy K, Stampfl G, Mohsenipour I, Fischer J, Grunert V. Treatment of the traumatic cerebral vasospasm with the calcium channel blocker nimodipine: a preliminary report. Neurol Res. 1984;6:29–32.PubMed

82.

Radhakrishnan D, Menon DK. Haemodynamic effects of intravenous nimodipine following aneurysmal subarachnoid haemorrhage: implications for monitoring. Anaesthesia. 1997;52:489–91. doi:10.1111/j.1365-2044.1997.112-az0105.x.CrossRefPubMed

83.

Wadworth AN, McTavish D. Nimodipine. A review of its pharmacological properties, and therapeutic efficacy in cerebral disorders. Drugs Aging. 1992;2:262–86. doi:10.2165/00002512-199202040-00002.

84.

Devlin JW, Coplin WM, Murry KR, Rengachary SS, Wilson RF. Nimodipine-induced acute hypoxemia: case report. Neurosurgery. 2000;47:1243–6; discussion 6–7. doi:10.1097/00006123-200011000-00048.

85.

Armin SS, Colohan AR, Zhang JH. Traumatic subarachnoid hemorrhage: our current understanding and its evolution over the past half century. Neurol Res. 2006;28:445–52. doi:10.1179/016164106X115053.CrossRefPubMed

86.

Zwienenberg-Lee M, Hartman J, Rudisill N, Muizelaar JP. Endovascular management of cerebral vasospasm. Neurosurgery. 2006;59:S139–47; discussion S3–13. doi:10.1227/01.NEU.0000239252.07760.59.

87.

Muizelaar JP, Zwienenberg M, Rudisill NA, Hecht ST. The prophylactic use of transluminal balloon angioplasty in patients with Fisher Grade 3 subarachnoid hemorrhage: a pilot study. J Neurosurg. 1999;91:51–8.PubMed

88.

Cairns CJ, Finfer SR, Harrington TJ, Cook R. Papaverine angioplasty to treat cerebral vasospasm following traumatic subarachnoid haemorrhage. Anaesth Intensive Care. 2003;31:87–91.PubMed

89.

Newell DW, Eskridge J, Mayberg M, Grady MS, Lewis D, Winn HR. Endovascular treatment of intracranial aneurysms and cerebral vasospasm. Clin Neurosurg. 1992;39:348–60.PubMed

Title: Posttraumatic Vasospasm Detected by Continuous Brain Tissue Oxygen Monitoring: Treatment with Intraarterial Verapamil and Balloon Angioplasty
Authors: Kiarash Shahlaie
James E. Boggan
Richard E. Latchaw
Cheng Ji
J. Paul Muizelaar
Publication date: 01-02-2009
Publisher: Humana Press Inc
Published in: Neurocritical Care / Issue 1/2009
Print ISSN: 1541-6933
Electronic ISSN: 1556-0961
DOI: https://doi.org/10.1007/s12028-008-9138-z

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Posttraumatic Vasospasm Detected by Continuous Brain Tissue Oxygen Monitoring: Treatment with Intraarterial Verapamil and Balloon Angioplasty

Abstract

Introduction

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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