AHA/ASA Guidelines for Post-aSAH Cerebral Vasospasm

In 2012, the American Heart Association (AHA) and the American Stroke Association (ASA) published updated evidence-based guidelines on the comprehensive management of aneurysmal subarachnoid hemorrhage (aSAH), including the management of cerebral vasospasm and delayed cerebral ischemia (DCI).^[13] These guidelines were endorsed by the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the Society of NeuroInterventional Surgery.

The 2012 AHA/ASA recommendations for management of cerebral vasospasm and DCI after aSAH are as follows^[13]:

Oral nimodipine should be administered to all patients with aSAH (class I; level of evidence, A) - It should be noted that this agent has been shown to improve neurologic outcomes but not cerebral vasospasm; the value of other calcium antagonists, whether administered orally or intravenously, remains uncertain
Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (class I; level of evidence, B) - Revised recommendation from previous guidelines
Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended(class III; level of evidence, B) - New recommendation
Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (class IIa; level of evidence, B) - New recommendation
Perfusion imaging with computed tomography (CT) or magnetic resonance imaging (MRI) can be useful to identify regions of potential brain ischemia (class IIa; level of evidence, B) - New recommendation
Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (class I; level of evidence, B) - Revised recommendation from previous guidelines
Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (class IIa; level of evidence, B) - Revised recommendation from previous guidelines

Medication

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Media Gallery

Diagnosis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage.
Initial presenting head CT scan showing subarachnoid hemorrhage and blood filling basal cisterns.
Initial cerebral angiogram from patient with subarachnoid hemorrhage.
Three-dimensional reconstruction of cerebral angiogram showing anterior communicating artery aneurysm.
Follow-up head CT scan showing subarachnoid blood.
Cerebral angiogram obtained on posthemorrhage day 5 in patient symptomatic from vasospasm. Angiogram shows severe narrowing of right anterior cerebral artery.

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Table 1. Recommendations for Endovascular Treatment of Cerebral Vasospasm

Table 1. Recommendations for Endovascular Treatment of Cerebral Vasospasm

Degree of Radiographic Vasospasm	Clinical Findings
	Asymptomatic	Symptomatic
Mild	No intervention	Vasodilation (rare)
Moderate	Vasodilation	Vasodilation ± balloon angioplasty
Severe	Vasodilation ± balloon angioplasty (rare)	Vasodilation + balloon angioplasty