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This eBook has been developed by Idorsia Pharmaceuticals Ltd as a resource
to improve understanding of cerebral vasospasm occurring after aneurysmal subarachnoid hemorrhage. It provides a useful summary of current information about the causes, signs and management of cerebral vasospasm. It highlights the impact it can have on the individual and those around them. It also outlines the strategies people caring for those affected by cerebral vasospasm can
use to manage their condition as effectively as possible.
The book is intended for the use of a general audience.
About this eBook
Disclaimer
This resource has been developed by Idorsia Pharmaceuticals Ltd in order to provide an environment to deliver a better understanding of aSAH and cerebral vasospasm and to pool information regarding the condition, the diagnosis procedure, available treatments and the impact it can have on the lives of
those affected. The resource is for use by a general audience.
The information in this resource is not intended as a substitute for advice/ treatment by a physician, whose instructions should always be followed. Neither does the information provided constitute an alternative to advice from a doctor or a pharmacist and should not be used on its own to produce a diagnosis or to commence or cease a particular treatment.
The links provided are for informational purposes only; they do not constitute
an endorsement or an approval from Idorsia of the services or opinions of the corporation, organization or individual. Idorsia bears no responsibility for the accuracy, legality or content of the external sites or subsequent links.
You are requested to contact the respective external site for answers to questions regarding its content.
The information provided is valid on the publication date but may be subject to further modifications. Even though Idorsia aims to provide accurate and up to date information at all times, please acknowledge that the present resource
is made available “as is”.
Idorsia does not give any warranty or representation, whether expressly stated
or implied, of any kind related to the comprehensiveness, usefulness, reliability
or timelines of the content of this resource. Idorsia cannot be held liable for any direct or indirect damage of a material or non-material nature that might be caused by the use or non-use of the information presented.
Disclaimer
You are requested to contact the respective external site for answers to questions regarding its content.
The information provided is valid on the publication date but may be subject to further modifications. Even though Idorsia aims to provide accurate and up to date information at all times., please acknowledge that the present resource is made available “as is”.
Idorsia does not give any warranty or representation, whether expressly stated or implied, of any kind related to the comprehensiveness, usefulness, reliability or timelines of the content of this resource. Idorsia cannot be held responsible for any direct or indirect damage of a material or non-material nature that might be caused by the use or non-use of the information presented.
Introduction
Aneurysmal subarachnoid hemorrhage (aSAH) is a sudden, life-threatening bleeding on the surface of the brain.
Symptoms of aSAH include a severe headache, confusion and numbness in the body, among other warning signs described in the following sections. Anyone who experiences these symptoms or recognizes them in others should call an ambulance immediately. Once in hospital, people with an aSAH will undergo surgery to stop the bleeding and prevent fatal re-bleeding.
Between a few days to two weeks into their recovery, about
a third of patients with aSAH experience a worsening of their neurological condition due to delayed cerebral vasospasm
– a constriction, or tightening, of arteries in the brain.
“It is very frustrating to see our patients survive the initial trauma of the brain hemorrhage and seemingly make a recovery, only for the vasospasm to take hold and cause significant long-term damage.”
— Physician
Introduction
Understanding aSAH and cerebral vasospasm
Diagnosis and management
of cerebral vasospasm
Long-term
impact of aSAH and cerebral vasospasm
Finding support
Cerebral vasospasm restricts blood flow to the brain and may subsequently lead to the death of blood-starved brain tissue, a consequence known medically as cerebral infarction and accompanied by poor long-term outcomes. Even when people make a good physical recovery, there is a high rate of lasting cognitive problems. Unfortunately, there is currently no way to predict which aSAH patients will have cerebral vasospasm, although some risk factors have been identified.
Currently, an invasive approach is used to treat cerebral vasospasm. This is associated with medical risks and often requires repeated procedures. Research into effective medical treatments is ongoing to improve the outlook for people with aSAH and cerebral vasospasm.
aSAH is classified as a type of stroke. Why does this type of bleeding on the brain occur, what is its impact on the brain and how is it treated?
Understanding aSAH and cerebral vasospasm
How is aSAH diagnosedand treated?
In addition to more ‘typical’ stroke-like symptoms, such as slurred speech, weakness on one side of the body and loss of consciousness, a hallmark symptom of aSAH is a sudden, intense and agonizing headache, which is often described by patients as a ‘thunderclap’ or ‘gunshot’ or ‘the worst headache of their life’.
Anyone experiencing or noticing someone else showing these symptoms should seek urgent medical assistance.
Once admitted to hospital, a number of tests may be conducted to confirm a diagnosis of aSAH, primarily a computed tomography (CT) scan to identify blood in the subarachnoid space. Other tests such as a lumbar puncture, a magnetic resonance imaging (MRI) scan, an angiogram (an X-Ray of blood vessels) and a neurologic examination, may be used to detect changes in the brain that may not be visible on a CT scan.
“It was very confusing, I was thinking ‘Why is this happening to my body’? I remember it would slowly happen, very slowly. I felt like I was losing feeling in the right side of my entire body. I had four vasospasm episodes that happened over two weeks.”
— Patient
Introduction
Understanding aSAH and cerebral vasospasm
Diagnosis and management
of cerebral vasospasm
Long-term
impact of aSAH and cerebral vasospasm
Finding support
Where does aSAH occur in the brain?
How is aSAH diagnosed
and treated?
Where does aSAH occur in the brain?
An aneurysmal subarachnoid hemorrhage (aSAH) is a sudden, life-threatening bleeding that occurs between two layers of the protective membranes surrounding the brain; the so-called subarachnoid space.
What is cerebral vasospasm and what causes it?
Cerebral vasospasm is the physical narrowing of a blood vessel in the brain which restricts or cuts off blood flow to the affected area.
While the exact causes of cerebral vasospasm are not fully understood, there are various physiological and biochemical reactions that may be triggered by aSAH – a bleed on the brain – that lead to the release of substances that constrict blood vessels.
What is cerebral vasospasm and what causes it?
Cerebral vasospasm is the physical narrowing of
a blood vessel in the brain which restricts or cuts off blood flow to the affected area.
While the exact causes of cerebral vasospasm are not fully understood, there are various physiological and biochemical reactions that may be triggered by aSAH – a bleed on the brain – that lead to the release of substances that constrict blood vessels.
"After making an excellent initial
recovery after the surgery, the devastating consequences of what the doctors call “vasospasms” was an absolute terrifying experience for my family during my two week recovery in the ICU."
The role of endothelin release in cerebral vasospasm
What happens when vasospasm occurs?
The role of endothelin release
in cerebral vasospasm
It is thought that cerebral vasospasm
is caused by the release of ‘vasoactive mediators’ after a bleed on the brain; biochemical ‘triggers’ that cause blood vessels to contract.
Endothelin is one of the most powerful,
long-acting vasoactive mediators that causes blood vessels to contract.
Patients with cerebral vasospasm show high levels of endothelin in their cerebral spinal fluid.
Greater understanding of the role that endothelin may play in causing cerebral vasospasm has led to new treatments that block its negative effect being researched as a potential way to prevent or reverse vasospasm in the future.
What happens when vasospasm occurs?
Cerebral vasospasm involves an abnormally strong contraction of the smooth muscle cells located in the wall of one or more blood vessel(s) in the brain.
This contraction narrows the blood vessel, limiting the amount of blood that can flow through it and decreasing the amount of blood reaching the part of the brain that the vessel supplies blood to.
How long and how much of the brain is deprived of blood will determine the extent of the short- or long-term damage caused to the individual.
How common is cerebral
vasospasm and who gets it?
Evidence of cerebral vasospasm can often be seen on an angiogram
(a special x-ray of blood vessels) in people who have had an aSAH, even when there are no apparent clinical symptoms. This means that there has been some narrowing of the blood vessels, but not enough to cause neurological deterioration. About 70% of aSAH patients show angiographic evidence of cerebral vasospasm, but only a third have clinical manifestations. There is no way to predict which patients will be affected.
"I am one of the lucky ones, not only to survive but also to have made a great recovery. I was told by my doctors that not all patients are that fortunate and I can only hope and pray that a cure for vasospasm can be found in the near future."
Signs and symptoms of cerebral vasospasm
Given the recovery period needed for aSAH, especially for patients who are kept anesthetized in the early stages, symptoms of cerebral vasospasm can be hard to spot, but may be most noticeable by a sudden change in the patient’s consciousness or new symptoms such as paralysis in certain parts of the body.
Blurred or double vision
Mood change, agitation
Worsening of headache
Difficulty speaking or being unable to speak
Dizziness
Confusion
Numbness or weakness
Loss of consciousness
What is the outlook for people with aSAH and cerebral vasospasm?
Those that survive aSAH will typically require rehabilitation. While some will recover well enough to live independently, many will face long-term symptoms such as physical or cognitive (‘thinking’) disabilities that require the support of a caregiver.
Disabilities are typically more severe in those that go on to experience cerebral vasospasm after aSAH. Cerebral vasospasm is one of the leading secondary causes of disability and death in those that experience aSAH.
"Despite improvements in the management of vasospasm, we are still limited in the treatment options currently available and vasospasm remains one of the most devastating complications of aSAH, leading to significant impact on short and
long-term outcomes."
“Prevention, early detection, and treatment of vasospasm are essential cornerstones of the medical management of patients post-aSAH, with the aim to prevent subsequent complications and poor clinical outcome.”
— Physician
Diagnosis and management
of cerebral vasospasm
What is cerebral vasospasm and what causes it?
Cerebral vasospasm is the physical narrowing of a blood vessel in the brain which restricts or cuts off blood flow to the affected area.
While the exact causes of cerebral vasospasm are not fully understood, there are various physiological and biochemical reactions that may be triggered by aSAH – a bleed on the brain – that lead to the release of substances that constrict blood vessels.
What tests are used to diagnose cerebral vasospasm?
How is cerebral vasospasm treated?
Rehabilitation
Rehabilitation
Depending on the extent of the damage caused by the aSAH and/or cerebral vasospasm, many people will need rehabilitation training and therapy. This usually starts in hospital and even once home, it’s common for people to regularly visit the hospital for rehabilitation appointments.
Rehabilitation training and therapy is usually delivered by a team of different types of specialists, including a neurologist to oversee the program, nurse specialists, physiotherapists, occupational therapists and speech and language therapists, to help the individual relearn any basic skills that aSAH and/or cerebral vasospasm may have impaired.
What tests are used to diagnose cerebral vasospasm?
Physical examination: to check for symptoms suggestive of cerebral vasospasm in people who have had a recent aSAH.
Cerebral angiography: to examine blood vessels in the brain using an x-ray machine, after injecting dye through them.
As noted previously, evidence of cerebral vasospasm can often be seen on an angiogram even when there are no apparent clinical symptoms. This means that there has been some narrowing of the blood vessels, but not enough to cause neurological deterioration. About 70% of aSAH patients show angiographic evidence of cerebral vasospasm, but only a third has clinical manifestations.
How is cerebral vasospasm treated?
In terms of prevention, the calcium channel antagonist or ‘blocker’ nimodipine may be beneficial in reducing the consequences of low blood supply to the brain in people who have had aSAH.
Subarachnoid hemorrhage
Treatment options for aSAH
Pre-treatment
Brain surgery:
Clipping of the aneurysm
Catheter intervention:
Releasing of platinum coils
Ruptured
aneurysm
Brain artery
Clip
Catheter
Coil
— Patient
— Patient
— Physician
To limit the damage caused by cerebral vasospasm, it is important that it is identified and treated as quickly
as possible.
Other tests, such as Transcranial Doppler (TCD), a type of scan using ultrasound waves to measure blood velocity through the brain's blood vessels, may also be used to detect vasospasm.
Cerebral vasospasm is typically treated with hemodynamic therapy. This involves inducing high blood pressure while keeping a healthy amount of fluid in the body’s circulatory system in the patient in an attempt to force a blood supply to the brain region affected by the vasospasm.
If this is not effective, some invasive methods
such as balloon angioplasty, where a small balloon is inserted into the constricted blood vessel and inflated to forcibly open the vessel, may be performed.
For those vessels not accessible to angioplasty, local injection of a vasodilator into the affected vessels is sometimes attempted. This is also an invasive procedure.
While these approaches are generally accepted for the treatment of severe cerebral vasospasm, evidence about their effectiveness is limited and they are labor intensive, can cause serious side effects and are associated with a risk of further brain damage. Many hospitals are not able to perform these procedures.
Research is ongoing to develop new treatment options for cerebral vasospasm in the future.
What is cerebral vasospasm and what causes it?
Cerebral vasospasm is the physical narrowing of a blood vessel in the brain which restricts or cuts off blood flow to the affected area.
While the exact causes of cerebral vasospasm are not fully understood, there are various physiological and biochemical reactions that may be triggered by aSAH – a bleed on the brain – that lead to the release of substances that constrict blood vessels.
“My aneurysm rupture was in 2003. I don’t remember having the vasospasms, but they were classified as moderate. I definitely went downhill. My comprehension got worse and did not recover. They treated me to alleviate the side effects and they subsided.”
— Patient
Work and employment
Friends and family
The emotional
impact of recovery
The emotional impact of recovery
Coming to terms with the sudden and unexpected mental or physical limitations following aSAH and cerebral vasospasm can be very difficult for the patient and their family and friends.
Being less able to do the same mental or physical tasks as before the event can impact self-worth, reduce confidence and lead to depression.
The family dynamic can change dramatically depending on the needs and abilities of the person recovering from aSAH and
cerebral vasospasm.
Friends and family may find it difficult to cope with the changes that cerebral vasospasm brings and be unsure how best to help in terms of both practical and emotional support.
Friends and family
It is normal for family members that take on the role of the caregiver to feel overwhelmed or resentful at times and/or guilty for harboring these feelings. It is important to remember that friends and family will go through their own ‘grieving’ process too. Sometimes it can be easier to speak to a stranger than a friend in these circumstances and there are often support networks for caregivers available within patient associations who share similar experiences.
Work and employment
Many people who experience aSAH and cerebral vasospasm are left with long-lasting damage to their memory, the speed at which they process information, their ability to analyze and understand shapes and spaces and their energy levels, all of which can affect someone’s capacity to work.
One study of aSAH patients treated over the course of a decade showed that of those previously in full or part-time employment, almost half were unemployed at follow-up a year later.
If someone is not working, or if a family member needs to take time off to care for that person, this can have a financial impact on the individual and the wider family.
Death to an area of brain tissue due to inadequate blood supply caused by cerebral vasospasm can have a lasting physical, social and emotional impact, affecting all aspects of someone’s life and the lives of their caregivers, family
and friends.
Long-term impact of aSAH and cerebral vasospasm
Rehabilitation and recovery can be a long and frustrating process and can put a strain on family life and change the family dynamic.
It’s important to remember that emotions are likely to change and most people will experience one or more of the so-called ‘five stages of grief’: denial, anger and frustration, depression/ withdrawal, bargaining, acceptance.
In order to reach the stage of acceptance, patients and their families will need to adjust their expectations and set new goals and objectives. It can be helpful to simply take one day at a time.
Stages of grief
Denial
Anger
Bargaining
Depression
Acceptance
Coronary artery spasm with cerebral vasospasm
What is cerebral vasospasm and what causes it?
Cerebral vasospasm is the physical narrowing of a blood vessel in the brain which restricts or cuts off blood flow to the affected area.
While the exact causes of cerebral vasospasm are not fully understood, there are various physiological and biochemical reactions that may be triggered by aSAH – a bleed on the brain – that lead to the release of substances that constrict blood vessels.
Life after aSAH can be extremely challenging and at times, overwhelming – most of those affected will need support from family and friends.
Rehabilitation and recovery can be a long process, so it is important for those who were negatively affected by aSAH and cerebral vasospasm (experiencing brain-tissue death as a result) to be realistic in their expectations of to what extent they will be able to relearn old skills or return to independence.
Finding support
The level of support for people and families affected by complications after aSAH, or stroke more broadly, of which cerebral vasospasm is one, varies greatly from country to country. Local associations and healthcare professionals can often be a good source of information about benefits, grants, social services and other resources available.
Many people find it helpful to become as informed about the condition as they can be. This can help them to feel more in control and manage expectations, as well as make note of any points to discuss with healthcare professionals at the next appointment.
What causes aSAH?
Any bleeding on the brain is very dangerous as the blood pools together and places pressure on the surrounding brain tissue. This, coupled with the interrupted blood supply due to the burst blood vessel, reduces much-needed blood flow to the brain and can cause severe damage.
While it’s not fully understood why some people develop aneurysms, there are certain factors such as genetics, high blood pressure and smoking, that increase the risk of an aneurysm developing and of it rupturing.
Unlike other types of brain hemorrhage, which can be caused by severe head injuries, aSAH is specifically caused by the rupture of an aneurysm – a weak, bulging spot on the wall of a brain artery – which allows blood to escape and accumulate in the space around the brain.
Symptoms
of cerebral
vasospasm
Symptoms of cerebral vasospasm
Introduction
Understanding aSAH and cerebral vasospasm
Diagnosis and management of cerebral vasospasm
Long-term impact of aSAH and cerebral vasospasm
Finding support
Patient support organizations
Patient support organizations
Patient support organizations are a good source of information and support on a variety of topics such as rehabilitation, psychological services, home adaptations, benefits and social services.
Some people find it helpful to attend support group meetings or to join online forums. Communicating with other people in a similar situation can help to avoid feelings of isolation.
Examples of organizations that offer this kind of support include:
Examples of organizations that offer this kind of support include:
-
Brain Aneurysm Foundation (www.bafound.org)
US-based organization with global reach, linking patients, families and the medical community in brain-aneurysm awareness, education, support, advocacy, and research funding
-
Joe Niekro Foundation (www.joeniekrofoundation.com) Organization providing patient services and education across the US and Canada, as well as funding research and engaging with international communities
Introduction
Understanding aSAH and cerebral vasospasm
Diagnosis and management of
cerebral vasospasm
Long-term impact of aSAH and cerebral vasospasm
Finding support
Introduction
Understanding aSAH and cerebral vasospasm
Diagnosis and management of cerebral vasospasm
Long-term impact of aSAH and cerebral vasospasm
Finding support
Baseline aSAH:
normal MCA
7 days after aSAH:
cerebral vasospasm
Blood flow is constricted during an artery spasm
Artery spasm
Subarachnoid hemorrhage bleeding
in the subarachnoid space
About this eBook
About this eBook
This eBook has been developed by Idorsia Pharmaceuticals Ltd as a resource
to improve understanding of cerebral vasospasm occurring after aneurysmal subarachnoid hemorrhage. It provides a useful summary of current information about the causes, signs and management of cerebral vasospasm. It highlights the impact it can
have on the individual and those around them. It also outlines the strategies people caring for those affected by cerebral vasospasm can
use to manage their condition as effectively
as possible.
The book is intended for the use of a general audience.
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Disclaimer
This resource has been developed by Idorsia Pharmaceuticals Ltd in order to provide an environment to deliver a better understanding of aSAH and cerebral vasospasm and to pool information regarding the condition, the diagnosis procedure, available treatments and the impact it can have on
the lives of those affected. The resource is for
use by a general audience.
The information in this resource is not intended as
a substitute for advice/treatment by a physician, whose instructions should always be followed. Neither does the information provided constitute an alternative to advice from a doctor or a pharmacist and should not be used on its own to produce
a diagnosis or to commence or cease a particular treatment.
The links provided are for informational purposes only; they do not constitute an endorsement or an approval from Idorsia of the services or opinions of the corporation, organization or individual. Idorsia bears no responsibility for the accuracy, legality or content of the external sites or subsequent links.
You are requested to contact the respective external site for answers to questions regarding its content.
The information provided is valid on the publication date but may be subject to further modifications. Even though Idorsia aims to provide accurate and up to date information at all times, please acknowledge that the present resource is made available “as is”.
Idorsia does not give any warranty or representation, whether expressly stated or implied, of any kind related to the comprehensiveness, usefulness, reliability or timelines of the content of this resource. Idorsia cannot be held liable for any direct or indirect damage of a material or non-material nature that might be caused by the use or non-use of the information presented.
Disclaimer
Understanding aSAH and cerebral vasospasm
About this eBook
This eBook has been developed by Idorsia Pharmaceuticals Ltd as a resource to improve understanding of cerebral vasospasm occurring after aneurysmal subarachnoid hemorrhage. It provides a useful summary of current information about the causes, signs and management of cerebral vasospasm. It highlights the impact it can have on the individual and those around them. It also outlines the strategies people caring for those affected by cerebral vasospasm can use to
manage their condition as effectively as possible.
The book is intended for the use of a general audience.
About this eBook
What is aSAH?
What is aSAH?
Diagnosis and management of cerebral vasospasm
Long-term impact of aSAH and cerebral vasospasm
Finding support
Scalp
Skull
Subarachnoid space
Brain
