Traumatic vasospasm
Traumatic brain injury (TBI) is significantly more common than aneurysm rupture. Subarachnoid haemorrhage (SAH) is observed in about 40% of severe and moderate TBI patients whereas post-traumatic vasospasm (tVSP) is observed in about 30–40% of TBI patient
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Traumatic vasospasm S. Stein, P. Le Roux Department of Neurosurgery, University of Pennsylvania, PA, U.S.A.
Summary Traumatic brain injury (TBI) is significantly more common than aneurysm rupture. Subarachnoid haemorrhage (SAH) is observed in about 40% of severe and moderate TBI patients whereas post-traumatic vasospasm (tVSP) is observed in about 30–40% of TBI patients. Traumatic vasospasm however can occur without SAH. Furthermore, recent pathological and animal studies in TBI and aneurysmal SAH suggest that coagulation abnormalities and intravascular microthrombosis, rather than vasospasm only, also can contribute to cerebral infarction. This will require further study. Today the diagnosis of tVSP is generally made with transcranial Doppler (TCD) or transcranial colour-coded sonography (TCCS) studies coupled with other cerebral blood flow measurements such as Xe-CT or perfusion-CT. Current published TBI management guidelines do not specifically address vasospasm. Cochrane analysis suggests that the use of calcium channel blockers in TBI does not improve outcome although in a subset of patients with tVSP there may be a small benefit. The mainstay of management is the prevention of secondary cerebral insults and the preservation of brain function rather than that of arterial diameter alone. Newer monitors such as brain oxygen monitors or cerebral microdialysis probes may facilitate this management. Keywords: Traumatic brain injury; subarachnoid haemorrhage; transcranial Doppler.
Introduction Traumatic brain injury (TBI) is extremely common. Population-based studies suggest an incidence as high as 600=100,000 [8]. In the United States, with a population of 300 million, each year TBI causes approximately 80,000 fatalities [38] and leaves 90,000 survivors with permanent disabilities [83]. One prominent pathological finding [22] and one which doubtless contributes to poor outcome is cerebral ischemia. Approximately 30–60% of patients suffering moderate to severe TBI also show evidence of subarachnoid haemorrhage (SAH) on neuroimaging studies [49, 53, 68]. Correspondence: Peter D. Le Roux, MD, Department of Neurosurgery, University of Pennsylvania, 330 S. 9th Street, PA 19107, U.S.A. e-mail: [email protected]
Although traumatic subarachnoid haemorrhage (tSAH) tends to occur in an older population, there is an independent risk of less favorable outcome when it occurs [49]. Many authorities point to a connection between traumatic subarachnoid haemorrhage and cerebral ischemia, considering the link to be spasm of the major cerebral vessels. This association is not unreasonable; spontaneous (nontraumatic) SAH is also frequently linked with both vasospasm (VSP) and cerebral ischemia. The association is so strong that the term ‘‘clinical vasospasm’’ has come to mean symptomatic cerebral ischemia occurring after SAH whether the SAH is associated with trauma or aneurysm rupture.
Traumatic subarachnoid haemorrhage and vasospasm Subarachnoid haemorrhage is observed in about 40% of patients with moderate or severe TBI. Pat
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