RESUMO
Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits. Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to performa comprehensive review and analysis of aneurysmal vasospasm. Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both. Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty. Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.
Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Nitroglicerina/uso terapêutico , Angioplastia com Balão/métodos , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/fisiopatologia , Vasoespasmo Intracraniano/terapia , Hemorragia Subaracnóidea/terapia , Vasodilatadores/uso terapêutico , Distribuição de Qui-Quadrado , Análise de Sobrevida , Análise de Regressão , Interpretação Estatística de DadosAssuntos
Hemorragia Cerebral/diagnóstico por imagem , Artéria Cerebral Média/diagnóstico por imagem , Milrinona/uso terapêutico , Transtornos Puerperais/tratamento farmacológico , Vasodilatadores/uso terapêutico , Vasoespasmo Intracraniano/tratamento farmacológico , Adulto , Angiografia Digital , Afasia de Broca/fisiopatologia , Edema Encefálico/diagnóstico por imagem , Edema Encefálico/etiologia , Edema Encefálico/fisiopatologia , Edema Encefálico/cirurgia , Hemorragia Cerebral/complicações , Hemorragia Cerebral/fisiopatologia , Angiografia por Tomografia Computadorizada , Craniectomia Descompressiva , Progressão da Doença , Drenagem , Feminino , Humanos , Hidrocefalia/etiologia , Hidrocefalia/fisiopatologia , Hidrocefalia/cirurgia , Hiperemia/diagnóstico por imagem , Artéria Cerebral Média/fisiopatologia , Nimodipina/uso terapêutico , Paresia/fisiopatologia , Transtornos Puerperais/diagnóstico por imagem , Transtornos Puerperais/fisiopatologia , Índice de Gravidade de Doença , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana , Vasoespasmo Intracraniano/complicações , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/fisiopatologia , VentriculostomiaRESUMO
OBJECTIVE: To describe patient characteristics, radiological findings and the clinical course of adults with fatal reversible cerebral vasoconstriction syndrome (RCVS). METHODS: A systematic literature search from January 1, 2000, until December 31, 2018, was performed using PubMed, EMBASE, Scopus, Cochrane reviews, LILACS and Scielo. Studies reporting RCVS in adult patients with fatal outcomes were included. RESULTS: 430 studies were initially identified, 179 full-text articles were reviewed, and 9 publications describing 12 subjects were included. The vast majority of the reports were from the U.S. Most of the female cases occurred during postpartum. All patients had a headache on initial presentation, although only 42% had thunderclap headache. A CT scan was performed on 67% of the patients. Imaging results were diverse, with a tendency toward cerebral hemorrhage followed by mixed cases. The main course of treatment included steroids (58% of the patients), with only 42% receiving nimodipine. The time to death ranged from 4 to 14â¯days, with a median of 9.2â¯days (SD⯱â¯3.2). CONCLUSION: We found that the majority of fatal cases reported in the literature are most likely related to postpartum angiopathy. We established a tendency in the onset of brain hemorrhage and the combination of infarction and brain hemorrhage. We described various markers for poor prognosis, including focal signs, the presence of hemorrhage and infarct in the first diagnostic image obtained and the need for invasive interventions. The majority of fatal cases in our report occurred in women, with over half of those cases during the puerperium period.
Assuntos
Vasoespasmo Intracraniano , Adulto , Feminino , Humanos , Masculino , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/patologia , Vasoespasmo Intracraniano/fisiopatologiaRESUMO
Despite its beneficial effects for the cardiovascular system, taurine remains a controversial substance. Taurine increases cardiac muscle strength and prevents arrhythmias, but its benefits go beyond this. Determining taurine levels may become an issue of life or death. In aneurysmal subarachnoid hemorrhage, taurine may be a warning signal informing of the risk of death in a patient. High plasma taurine levels may identify those patients at a high risk for death or a vegetative state at discharge from the hospital; thus, taurine may be a vital marker for the prognosis of this disorder. This is even more relevant considering that the result occurred in patients with a good neurological grade at admission that would usually receive a good prognosis but, despite this, one out of four died or remained in a vegetative state. Maybe taurine is key to explain this apparent paradox.
Assuntos
Hemorragia Subaracnóidea/fisiopatologia , Taurina/sangue , Biomarcadores , Edema Encefálico/etiologia , Edema Encefálico/fisiopatologia , Humanos , Prognóstico , Hemorragia Subaracnóidea/sangue , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/etiologia , Vasoespasmo Intracraniano/fisiopatologiaRESUMO
Background: Early mobilization in intensive care units (ICU) provides respiratory, neurological and cardiovascular benefits in hospitalized patients. However, the orthostatic effects of changing from a supine to a sitting position may interfere with cerebral hemodynamics of patients with aneurysmal subarachnoid hemorrhage (aSAH). Aim: To describe the changes in mean cerebral blood flow velocity (MCBFV) in supine and sitting position, in adult patients with aSAH, with asymptomatic vasospasm (AVS) or without vasospasm (VS) at a neurosurgical ICU. Material and Methods: Descriptive case series study in 21 patients with aSAH, both with and without VS. They were positioned in a supine 30° position and then seated at the edge of bed for six minutes. MCBFV was measured by transcranial Doppler (TCD), and hemodynamic variables in both positions were registered. After this basal assessment and for 21 days after the episode of SAH, patients were seated once a day and signs of VS were recorded. Results: No significant changes in MCBFV or hemodynamic variables were detected during position changes, except for an increase in heart rate in the sitting position. No patient with AVS at the onset, had symptomatic VS during the 21 days of follow up when patients were seated. Among patients with a normal MCBFV at baseline, five patients (24%) had VS at a mean of three days after the first time that they were seated on the edge of bed. Conclusions: Sitting patients at the edge of the bed is a safe mobilization alternative for patients who suffered aSAH who did not have VS or had AVS.
Assuntos
Adulto , Feminino , Humanos , Masculino , Circulação Cerebrovascular/fisiologia , Posicionamento do Paciente/métodos , Hemorragia Subaracnóidea/fisiopatologia , Decúbito Dorsal/fisiologia , Vasoespasmo Intracraniano/fisiopatologia , Velocidade do Fluxo Sanguíneo/fisiologia , Posicionamento do Paciente/efeitos adversos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea , Ultrassonografia Doppler Transcraniana , Vasoespasmo Intracraniano/etiologia , Vasoespasmo IntracranianoRESUMO
Aneurysmal subarachnoid haemorrhage is one of the most deleterious acute neurological diseases. The cerebral ischemia secondary to arterial vasospasm occurring after aneurysmal subarachnoid haemorrhage is still responsible for the considerable morbidity and mortality in these patients. Besides the knowledge of basic mechanisms of cerebral vasoespasm following aneurysmal subarachnoid haemorrhage, the prophylaxis and treatment of this pathology however still remain suboptimal. There issome evidence that acute erythropoietin treatment may reduce the severity of cerebral vasospasm and eventually improve outcome in aneurysmal subarachnoid haemorrhage patients. There are underlying mechanisms extend far beyond erythropoiesis: like enhancing neurogenesis, decreasing inflammation and apoptosis inhibition. In this review the authors describe many of the biologic effects, especially experimental studies and clinical studies that reported why the erythropoietin could be beneficial topatients with aneurysmal subarachnoid haemorrhage.
A hemorragia subaracnóidea é uma das doenças neurológicas agudas mais graves. A isquemia cerebral secundária ao vasoespasmo arterial após a hemorragia ainda é responsável por considerável morbidade e mortalidade nesses pacientes. Ao lado do conhecimento dos mecanismos básicos do vasoespasmo na hemorragia subaracnóidea, a profilaxia e o tratamento dessa entidade ainda são insuficientes. Há evidências de que o uso da eritropoietina na fase aguda pode reduzir a gravidade do vasoespasmo e,eventualmente, melhorar o prognóstico desses pacientes. Há mecanismos de ação da eritropoietina que vão além da eritropoiese como neurogênese, redução da inflamação e inibição da apoptose. Nesta revisão, os autores elucidam inúmeros efeitos biológicos, principalmente aqueles demonstrados nos estudos experimentais e clínicos que descrevem por que a eritropoietina pode ser benéfica em pacientes com hemorragia subaracnóidea.
Assuntos
Eritropoetina/administração & dosagem , Vasoespasmo Intracraniano/fisiopatologia , Vasoespasmo Intracraniano/tratamento farmacológico , Vasoespasmo Intracraniano/diagnóstico por imagem , Angiografia Cerebral/métodos , Isquemia Encefálica/complicaçõesRESUMO
BACKGROUND: Early mobilization in intensive care units (ICU) provides respiratory, neurological and cardiovascular benefits in hospitalized patients. However, the orthostatic effects of changing from a supine to a sitting position may interfere with cerebral hemodynamics of patients with aneurysmal subarachnoid hemorrhage (aSAH). AIM: To describe the changes in mean cerebral blood flow velocity (MCBFV) in supine and sitting position, in adult patients with aSAH, with asymptomatic vasospasm (AVS) or without vasospasm (VS) at a neurosurgical ICU. MATERIAL AND METHODS: Descriptive case series study in 21 patients with aSAH, both with and without VS. They were positioned in a supine 30° position and then seated at the edge of bed for six minutes. MCBFV was measured by transcranial Doppler (TCD), and hemodynamic variables in both positions were registered. After this basal assessment and for 21 days after the episode of SAH, patients were seated once a day and signs of VS were recorded. RESULTS: No significant changes in MCBFV or hemodynamic variables were detected during position changes, except for an increase in heart rate in the sitting position. No patient with AVS at the onset, had symptomatic VS during the 21 days of follow up when patients were seated. Among patients with a normal MCBFV at baseline, five patients (24%) had VS at a mean of three days after the first time that they were seated on the edge of bed. CONCLUSIONS: Sitting patients at the edge of the bed is a safe mobilization alternative for patients who suffered aSAH who did not have VS or had AVS.
Assuntos
Circulação Cerebrovascular/fisiologia , Posicionamento do Paciente/métodos , Hemorragia Subaracnóidea/fisiopatologia , Decúbito Dorsal/fisiologia , Vasoespasmo Intracraniano/fisiopatologia , Adulto , Velocidade do Fluxo Sanguíneo/fisiologia , Feminino , Humanos , Masculino , Posicionamento do Paciente/efeitos adversos , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico por imagem , Ultrassonografia Doppler Transcraniana , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologiaRESUMO
The Fisher revised scale (FRS) presents an alternative for evaluating patients with subarachnoid hemorrhage (SAH). In this study, we compared the prognosis of patients with SAH and vasospasms (VSP). METHOD: This was a prospective study on patients with a diagnosis of aneurysmal SAH, 72 hours after the initial event. Sequential neurological examinations and Hunt and Hess (HaH) score were performed on the 1st, 7th and 14th days. Transcranial Doppler was used to assess vasospasms. RESULTS: Out of the 24 patients studied, ten (41.66 percent) presented a delayed neurological deficit, such as diminished consciousness, decreased HaH score or death. The single patient classified as FS-1 did not have any delayed neurological deficit, while such deficits evolved in one patient out of five with FS-2 (20 percent); two out of seven with FS-3 (28.57 percent) and seven out of 11 with FS-4 (63.63 percent). CONCLUSION: Level three of the FS and FRS seemed to be compatible with regard to predicting the likelihood of progression to severe VSP.
A escala revisada de Fisher (FRS) representa uma alternativa para avaliação de pacientes com hemorragia subaracnóidea (HSA). Neste estudo comparamos a evolução prognóstica referente ao vasoespasmo (VSP) nos pacientes com HSA. MÉTODO: Estudo prospectivo em pacientes com diagnóstico de HSA, com 72 horas após o evento inicial. Escala de Hunt e Hess (HeH) foi realizada no 1º, 7º, 14º dia. Utilizamos Doppler transcraniano para avaliação de VSP. RESULTADOS: Dos 24 pacientes estudados dez (41,66 por cento) tiveram déficit neurológico tardio (DNT), como diminuição da consciência, grau de HeH ou morte. Um paciente de cinco classificados como FS-2 (20 por cento), dois de sete pacientes com FS-3 (28,57 por cento) e sete de 11 pacientes com FS-4 (63,63 por cento) evoluíram com DNT. Para o FRS não encontramos piora neurológica precoce no paciente com FRS-0. CONCLUSÃO: O nível três da FS e FRS parecem ser comparáveis, quando se trata de predizer a probabilidade de progressão para VSP grave.
Assuntos
Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Subaracnóidea/fisiopatologia , Vasoespasmo Intracraniano/fisiopatologia , Progressão da Doença , Prognóstico , Estudos Prospectivos , Índice de Gravidade de Doença , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea , Tomografia Computadorizada por Raios X , Vasoespasmo Intracraniano/etiologia , Vasoespasmo IntracranianoRESUMO
INTRODUCTION: Symptomatic vasospasm in the setting of a subarachnoid hemorrhage is a complication of difficult diagnosis in some clinical situations. Objectives. Describe the clinical characteristics of cerebral vasospasm demonstrated by neurovascular studies in patients with ruptured saccular aneurysm. PATIENTS AND METHODS: 19 consecutive patients with symptomatic vasospasm, evaluated with TCD and any variant of neurovascular study with contrast injection. All these cases were in degrees between 1 and 3 of the World Federation of Neurological Surgeons Scale. RESULTS: The cognitive and behavioral manifestations were the most frequent (53%), followed by neurological focal deficits (26%). Clinical vasospasm occurred most frequently between day 9 and 10. Vasospasm is predominant in the arteries of the anterior circulation. The high mortality (42%) and the antecedent of arterial hypertension characterized the group with symptomatic vasospasm. There was no statistical relationship between the result of the scale of Fisher and the symptomatic vasospasm. All the TCD parameters had statistical significance. CONCLUSIONS: The clinical manifestations more frequently associated with symptomatic vasospasm were cognitive and behavioral. This group of patients is characterized by a high mortality. The TCD is a test of great value to predict cerebral ischemia due to vasospasm.
Assuntos
Vasoespasmo Intracraniano/fisiopatologia , Adulto , Comportamento/fisiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/patologia , Isquemia Encefálica/fisiopatologia , Transtornos Cognitivos/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vasoespasmo Intracraniano/complicações , Vasoespasmo Intracraniano/diagnóstico , Vasoespasmo Intracraniano/patologiaRESUMO
UNLABELLED: The Fisher revised scale (FRS) presents an alternative for evaluating patients with subarachnoid hemorrhage (SAH). In this study, we compared the prognosis of patients with SAH and vasospasms (VSP). METHOD: This was a prospective study on patients with a diagnosis of aneurysmal SAH, 72 hours after the initial event. Sequential neurological examinations and Hunt and Hess (HaH) score were performed on the 1(st), 7(th) and 14(th) days. Transcranial Doppler was used to assess vasospasms. RESULTS: Out of the 24 patients studied, ten (41.66%) presented a delayed neurological deficit, such as diminished consciousness, decreased HaH score or death. The single patient classified as FS-1 did not have any delayed neurological deficit, while such deficits evolved in one patient out of five with FS-2 (20%); two out of seven with FS-3 (28.57%) and seven out of 11 with FS-4 (63.63%). CONCLUSION: Level three of the FS and FRS seemed to be compatible with regard to predicting the likelihood of progression to severe VSP.