gms | German Medical Science

Objective: Cerebral vasospasm (CV) is a major cause for disability following aneurismal subarachnoid hemorrhage (aSAH). aSAH has a 30-day mortality rate of 45% and leaves 30% of survivors disabled. Narrowing of large cerebral vessels averagely occurs 3-14 days after aSAH and often leads to delayed cerebral ischemia (DCI). Standard treatment for aSAH patients with suspected CV is nimodipine and induced hypertension, which can be escalated to angioplasty of the large cerebral vessels. Ganglion stellate block (GSB) was shown to significantly lower cerebral blood flow velocity (CBFV) due to decrease in vascular tone. In contrast to angioplasty it is a minimally invasive, bedside applicable treatment. Our study elicits further evidence for lowering of CBFV after GSB application in aSAH patients.

Methods: Data from patients admitted to our intensive care unit (ICU) between 2013 and 2016 with aSAH and severe CV were collected from the hospital’s database. After endovascular occlusion or surgical clipping, standard treatment at the time of hospitalisation consisted of nimodipine (oral 60 mg/4h or iv 2mg/h) for at least 14 days, regular neurological evaluation (every 8h) and transcranial Doppler sonography (TCD) every 24h. If clinical signs of CV were observed and / or TCD showed elevated CBFV (≥120 cm/s) hypertension was induced. If symptoms persisted, GSB was performed on the ipsilateral side of CBFV elevation. Patients were re-evaluated neurologically and with TCD 2-24 hours after GSB. If severe CV still persisted angiography was performed. Increase or decrease beyond 100 cm/s or 50% in MCA (median cerebral artery) blood flow velocity were not eligible.

Results: 43 patients received GSB. Data of 36 patients were analyzed (mean age 48.9 ± 12.4 years, f:m=23:13, clipping n = 10, coiling n = 25). In one patient aneurism treatment failed. Median Hunt & Hess (HH) grade in treated patients was 4 and Fisher grade (FG) was 4. GSB was administered after 7.1 days (±3) following admission. The blood flow velocity (BFV) in the ipsilateral MCA decreased after GSB administration in 80.6% of patients, by a mean of 26.5 (±39.1) cm/s from baseline 157.3 (±27.3) (P<0.001). The contralateral MCA showed a less marked BFV decrease of 17.4 (±33.1) cm/s from baseline (122.6±42.1) within 2 - 24h after GSB (P<0.001). The decrease in CBFV following GSB showed no relation to gender, age, HH and FG. No major complications resulting from GSB where observed in this cohort. 19 patients were significantly disabled (Modified Rankin Scale score ≥4), five patients died in the ICU.

Conclusion: Our preliminary data demonstrate a decrease of CBFV in over 80 % of patients with a mean reduction of 16% after GSB. Our results confirm GSB as a safe technique with potential merit in the treatment of CV.