PubMed · 15911844
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Cathal O'Donnell, Richard Verbeek. 2005-05-24. Guidelines for STEMI.. https://doi.org/10.1503/cmaj.1041729
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Cerebral vasospasm remains a major source of morbidity and death in patients with aneurysmal subarachnoid hemorrhage (SAH). When vasospasm becomes refractory to maximal medical management consisting of induced hypertension and hypervolemia and administration of calcium channel antagonists, endovascular therapies should be considered. The primary goal of endovascular treatment is to increase cerebral blood flow to prevent cerebral infarction. Two of the more frequently studied endovascular treatments are transluminal balloon angioplasty and intraarterial papaverine infusion. These two have been used either alone or in combination for the treatment of vasospasm. Other pharmacological vasodilating agents currently being investigated are intraarterial nimodipine, nicardipine, verapamil, and milrinone. Newer intraarterial agents, such as fasudil and colforsin daropate, have also been investigated. In this article the authors review the current options in terms of endovascular therapies for treatment of cerebral vasospasm. The mechanism of action, technique of administration, clinical effect and outcomes, and complications of each modality are discussed.
After a first cerebral ischemic event, secondary prevention should be started as soon as possible, especially in transient ischemic attacks where the risk of recurrence is the highest, especially during the first week, needing a diagnostic workup in a short period of time, secondary prevention measures depending on the presumed cause of the event. Secondary prevention of vascular events after transient ischemic attack or cerebral infarct consists of 3 types of strategies: 1. treatment of risk factors for stroke, especially high blood pressure, high cholesterol and smoking cessation; 2. aspirin (50 to 325 mg), or clopidogrel, or association aspirine-dipyridamole in high-risk subjects, or warfarin in patients with high-risk cardiopathies; and 3. carotid surgery in patients selected by clinical and imaging criteria. Other strategies are currently partly under evaluation: statins in normocholesterolemic ischemic stroke patients without coronary event, angioplasty with stenting. Audits of practice are necessary to determine whether patients are actually treated according to scientific evidence. This is a crucial issue if we want the results of trials to be translated in the true life, and really improve health at the community level.