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TECHNICAL NOTE
Year : 2012  |  Volume : 7  |  Issue : 2  |  Page : 78-80

Innovative approach for prevention and treatment of post subarachnoid hemorrhage vasospasm: A preliminary report


1 Department of Neurosurgery, Advanced Neuro Science Institute, BGS Global Hospital, Bangalore, Karnataka, India
2 Visiting Consultant Neurosurgeon, Mediterraneo Hospital, Athens, Greece

Date of Web Publication18-Jul-2012

Correspondence Address:
Neelam K Venkataramana
Neurosurgeon, Founder- Comprehensive Trauma Consortium, BGS Health and Education City, No. 67, Uttarahalli Road, Kengeri, Bangalore - 560 060, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1793-5482.98650

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  Abstract 

More than one third of patients with subarachnoid hemorrhage (SAH) develop clinically significant vasospasm, as a leading morbidity and mortality factor for these patients. It is widely accepted that a) Degradation products of blood are the causative factors of vasospasm b) The amount of subarachnoid blood seen on admission CT is correlated to the risk of vasospasm c) Reducing the subarachnoid clot burden at the time of surgery reduces the risk of vasospasm. But there is no existing method to clear the blood from subarachnoid spaces satisfactorily. We have evaluated safety and feasibility of fluid exchange catheter system in SAH, to achieve this goal. We were successful in clearing cisternal blood in three patients with aneurysmal rupture with fluid exchange catheter system. Baseline CT scan of brain was performed immediately after the surgery and then at the end of irrigation. The amount of subarachnoid blood was evaluated. This innovative, fluid exchange catheter system infuses and aspirates micro volumes of drug solution in a cyclic mode, ensuring isobaric exchange of fluids. The result is good clearance of blood in subarachnoid spaces were seen in all the patients. Also, significant improvement in neurological deficits secondary to vasospasm was seen. We conclude that the fluid exchange catheter system is safe and adoptable in neurosurgical practice.

Keywords: Cisternal blood, flux irrigation system, subarachnoid hemorrhage, vasospasm


How to cite this article:
Venkataramana NK, Rao SA, Naik AL, Shetty K, Murthy P, Bansal A, Panotopoulos C. Innovative approach for prevention and treatment of post subarachnoid hemorrhage vasospasm: A preliminary report. Asian J Neurosurg 2012;7:78-80

How to cite this URL:
Venkataramana NK, Rao SA, Naik AL, Shetty K, Murthy P, Bansal A, Panotopoulos C. Innovative approach for prevention and treatment of post subarachnoid hemorrhage vasospasm: A preliminary report. Asian J Neurosurg [serial online] 2012 [cited 2017 May 24];7:78-80. Available from: http://www.asianjns.org/text.asp?2012/7/2/78/98650


  Introduction Top


The outcome of subarachnoid hemorrhage (SAH) is often complicated by the occurrence of vasospasm. Angiographic vasospasm is seen in 30-70% of patients with aneurysmal SAH. [1],[2] Of these symptoms of cerebral ischemia with high risk of debilitating stroke and mortality, clinically significant spasms can occur in 20-30% of patients. [3] Many theories have been proposed and several treatment regimens have been tried to treat vasospasm. Till date, there is no satisfactory method to adequately treat vasospasm. Among the several variables, the amount of subarachnoid blood has significant correlation to the development of spasm. [4],[5] It is also well known that clearing of blood from the cisterns during surgery helps in reducing the incidence and severity of vasospasm. Technically, it may be difficult and invasive to clear all the blood satisfactorily.


  Innovation Top


We have used a fluid exchange catheter system (FLUX) which infuses and aspirates micro volumes of fluid and drug solution in a cyclic mode. This is done in an isobaric exchange of fluids and can clear cisternal blood after aneurysm surgery.


  Clinical Data Top


With scientific and ethical approval, as well as with written informed consent from the patient and/or legally acceptable representative, FLUX catheter was placed in the subarachnoid space after aneurysm clipping in three patients with severe SAH (Fisher grade 3). We used an average of five liters of Ringer's Lactate with papavarine at a concentration of 8×10-5 M, for 72 hours, starting immediately after surgery. CT scan performed at the end of this period showed no residual blood in the subarachnoid spaces in all the three patients. Patient 1 did not develop any vasospasm and was discharged with intact neurological status [Figure 1]a and b. Patients' 2 and 3, who had already severe vasospasm on admission, improved significantly, clinically, over four to six weeks, and was also discharged with no neurological deficit [Figure 2]a and b.
Figure 1: (a) Preoperative CT brain scan showing SAH in Rt. sylvian fissure and Rt. ambient cistern (b) CT brain scan showing clearance of subarachnoid blood (post-FLUX use)

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Figure 2: (a) CT brain scan showing hematoma and subarachnoid blood in right ambient cistern, immediately after clipping (b) Seventy two hours post-irrigation CT brain scan showing clearance of subarachnoid blood, FLUX catheter in situ

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  Discussion Top


More than one third of patients with subarachnoid hemorrhage (SAH) develop clinically significant vasospasm, as a leading morbidity and mortality factor for these patients. [6] It is widely accepted that a) Degradation products of blood are the causative factors of vasospasm [7],[8] b) The amount of subarachnoid blood seen on admission CT is correlated to the risk of vasospasm [9] c) Reducing the subarachnoid clot burden at the time of surgery reduces the risk of vasospasm.

Clearing the subarachnoid blood from cisterns following aneurysm rupture remains a technical challenge. Neurosurgeons adopted variety of irrigation methods and drains intra- and post-operative period, respectively. Risk of increasing intracranial pressure (ICP) in adequate clearance and infection were the usual risks. We have over come these problems with FLUX double lumen catheter which infuses and simultaneously aspirates fluid. Since it is a volume regulated and pressure controlled system through a built-in programmed soft ware, there in risk of increasing ICP. In our experience, 72 hours are more than sufficient, and hence, risk of infection is negligible. We have not only found it effective, but also have found the advantage of infusing a drug in micro quantities and deriving the best therapeutic benefit in addition. In our preliminary experience, there were no notable complications, safe and user friendly. The clinical benefits associated are very much encouraging to make this method as part of SAH treatment protocol.


  Conclusion Top


The FLUX fluid exchange system is an effective method for clearing blood in the subarachnoid spaces with the infusion of drug, leading to either prevention or clearance of vasospasm with clinical benefit. This is a safe and adoptable method in neurosurgical practice.

 
  References Top

1.Dorsch NW. Cerebral arterial spasm - A clinical review. Br J Neurosurg 1995;9;403-12.  Back to cited text no. 1
    
2.Heros RC, Zervas NT, Varsos V. Cerebral vasospasm after subarachnoid hemorrhage: An update. Ann Neurol 1983;14:599-608.  Back to cited text no. 2
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3.Lazaridis C, Naval N. Risk factors and medical management of vasospasm after subarachnoid hemorrhage. Neurosurg Clin N Am 2010;21:353-64.  Back to cited text no. 3
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4.Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Copeland D, et al. Effect of Cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhate; the fisher scale revisited. Stroke 2001;32:2012-20.  Back to cited text no. 4
    
5.Fronstera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES Jr, et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: The modified fisher scale. Neurosurgery 2006;59:21-7.  Back to cited text no. 5
    
6.Qureshi AI, Sung GY, Suri MA, Straw RN, Guterman LR, Hopkins LN. Prognostic value and determinants of ultra-early vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery 1999;44:967-74.  Back to cited text no. 6
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7.Kolias AG, Sen J, Belli AJ. Pathogenesis of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Putative mechanisms and novel approaches. Neurosci Res 2009;87:1-11.  Back to cited text no. 7
    
8.Macdonald RL, Weir BK. A review of hemoglobin and the pathogenesis of cerebral vasospasm. Stroke 1991;22:971-82.  Back to cited text no. 8
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9.Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980;6:1-9.  Back to cited text no. 9
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