Traumatic brain injury and intracranial hemorrhage–induced cerebral vasospasm: a systematic review

Fawaz Al-Mufti, Krishna Amuluru, Abhinav Changa, Megan Lander, Neil Patel, Ethan Wajswol, Sarmad Al-Marsoummi, Basim Alzubaidi, I. Paul Singh, Rolla Nuoman, Chirag Gandhi
2017 Neurosurgical Focus  
FOCUS Neurosurg Focus 43 (5): E14, 2017 T he incidence and impact of traumatic brain injury (TBI) within the general population have increased over the past few years. 6 Although the primary injury associated with TBI may be debilitating, secondary injury associated with posttraumatic arterial vasospasm is an important and dangerous consequence of TBI. The incidence of vasospasm in aneurysmal subarachnoid hemorrhage (aSAH) has been extensively studied; less is known regarding the epidemiology
more » ... the epidemiology of posttraumatic vasospasm (PTV), with the largest study examining only 299 patients. 25 Because of limited studies and small numbers of enrolled patients, PTV continues to be poorly characterized. Current literature suggests that PTV portends a more severe neurological injury, but its magnitude is un-ABBREVIATIONS aSAH = aneurysmal SAH; CBF = cerebral blood flow; CTA = CT angiography; CTP = CT perfusion; DCI = delayed cerebral ischemia; DSA = digital subtraction angiography; EEG = electroencephalography; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; MCA = middle cerebral artery; PbtO 2 = brain tissue oxygen; PTV = posttraumatic vasospasm; SAH = subarachnoid hemorrhage; TBI = traumatic brain injury; TCD = transcranial Doppler. OBJECTIVE Little is known regarding the natural history of posttraumatic vasospasm. The authors review the pathophysiology of posttraumatic vasospasm (PTV), its associated risk factors, the efficacy of the technologies used to detect PTV, and the management/treatment options available today. METHODS The authors performed a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed, Google Scholar, and CENTRAL (the Cochrane Central Register of Controlled Trials). Outcome variables extracted from each study included epidemiology, pathophysiology, time course, predictors of PTV and delayed cerebral ischemia (DCI), optimal means of surveillance and evaluation of PTV, application of multimodality monitoring, modern management and treatment options, and patient outcomes after PTV. Study types were limited to retrospective chart reviews, database reviews, and prospective studies. RESULTS A total of 40 articles were included in the systematic review. In many cases of mild or moderate traumatic brain injury (TBI), imaging or ultrasonographic studies are not performed. The lack of widespread assessment makes finding the true overall incidence of PTV a difficult endeavor. The clinical consequences of PTV are important, given the morbidity that can result from it. DCI manifests as new-onset neurological deterioration that occurs beyond the timeframe of initial brain injury. While there are many techniques that attempt to diagnose cerebral vasospasm, digital subtraction angiography is the gold standard. Some predictors of PTV include SAH, intraventricular hemorrhage, low admission Glasgow Coma Scale (GCS) score (< 9), and young age (< 30 years). CONCLUSIONS Given these results, clinicians should suspect PTV in young patients presenting with intracranial hemorrhage (ICH), especially SAH and/or intraventricular hemorrhage, who present with a GCS score less than 9. Monitoring and regulation of CNS metabolism following TBI/ICH-induced vasospasm may play an important adjunct role to the primary prevention of vasospasm. https://thejns.org/doi/abs/10.3171/2017.8.FOCUS17431 KEY WORDS traumatic intracranial hemorrhage; posttraumatic vasospasm; traumatic brain injury ©AANS, 2017
doi:10.3171/2017.8.focus17431 pmid:29088959 fatcat:iytsdvr3qnfxlny423vlimvln4