Are you looking for more information about vasospasm after a brain hemorrhage?

Introduction

Vasospasm explained by Idorsia

“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

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.

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 is accompanied with 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, which 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.

Understanding aSAH and cerebral vasospasm

Fabry disease explained by Idorsia

“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

What is aSAH?

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?

  • + What causes aSAH?
    • 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.
    • 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.
    • 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.

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.”

- Patient
  • + 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.

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 has 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.”

- Patient

Signs and symptoms of cerebral vasospasm

Given the recovery period needed for aSAH, especially for patients who are kept anaesthetized 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.

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.”

- Physician

Diagnosis and management of cerebral vasospasm

Insomnia condition damage to long-term health

“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

To limit the damage caused by cerebral vasospasm, it is important that it is identified and treated as quickly as possible.

  • + 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.
    • 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.
  • + 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.
    • 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.
  • + 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.

Long-term impact of aSAH and cerebral vasospasm

insomnia gets in the way of everything

“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

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.

  • + 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.
  • + Friends and family
    • 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.
    • 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.

Finding support

Guidance on managing Fabry disease

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.

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.

  • + 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:
      • 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