Multichannel near-infrared spectroscopy as a tool for assisting intra-arterial fasudil therapy for diffuse vasospasm after subarachnoid hemorrhage

Abstract

Background:Diffuse cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) refractory to medical management can be treated with intra-arterial administration of vasodilators, but valid bedside monitoring for the diagnosis and therapeutic assessment is poorly available. We demonstrate the successful application of regional cerebral oxygen saturation (rSO2) monitoring with multichannel near-infrared spectroscopy (NIRS) in assisting intra-arterial infusions of fasudil hydrochloride to a patient suffering from post-SAH vasospasm in the distal vascular territories.Case Description:A 63-year-old man presented with SAH and intracerebral hematoma due to ruptured right middle cerebral artery aneurysm developed aphasia and right-sided weakness on day 9 after SAH onset. Delayed cerebral ischemia attributable to diffuse vasospasm in the distal territories of the left anterior and middle cerebral arteries was suspected. Since the symptoms persisted despite maximal hyperdynamic therapy with dobutamine, intra-arterial fasudil treatment in the setting of rSO2 monitoring including the spasm-affected vascular territory with four-channel flexible NIRS sensors was subsequently performed. Decreased and fluctuating rSO2 in angiographically documented vasospastic territories increased immediately after intra-arterial fasudil infusion in accordance with relief of vasospasm that correlated with neurological improvement. The procedure was repeated on day 11 since the effect was transient and neurological deterioration and reduction of rSO2 recurred. The deficits resolved accompanied by uptake and maintenance of rSO 2 following the intra-arterial fasudil, resulting in favorable functional outcome.Conclusion:Continuous rSO2 monitoring with multichannel NIRS is a feasible strategy to assist intraarterial fasudil therapy for detecting and treating the focal ischemic area exposed to diffuse vasospasm.

Multimodal Monitoring in Subarachnoid Hemorrhage

“…37,38 In patients with a new focal neurological deficit, NIRS detected decreased cerebral oxygenation in the affected region and a rise in oxygenation after treatment with an inotrope. 39,40 However, others have found no such correlation. 41,42 Brain Tissue Oximetry Partial pressure of brain tissue oxygen (PbtO 2 ) is a complex physiological variable that likely reflects the interaction among oxygen delivery, extraction, and tissue demands.…”

Performance of Third-generation FloTrac/Vigileo system during hyperdynamic therapy for delayed cerebral ischemia after subarachnoid hemorrhage

“…Patients were treated according to the SAH treatment protocol of our institution,[ 18 – 21 23 ] including daily transcranial Doppler as screening for vasospasm. They rested in bed up to day 14 with intravenous fluids of 1,500–4,000 mL/day and oral food intake or nasogastric tube nutrition of 1,200–1,800 kcal/day to keep daily fluid balance at 750 mL positive (compensating for insensible fluid loss) and serum albumin concentration ≥ 3 g/dL.…”

Fasudil combined with methylcobalamin or lipoic acid can improve the nerve conduction velocity in patients with diabetic peripheral neuropathy

“…[ 43 – 45 ] In addition, F can inhibit nerve cell apoptosis by reducing inflammatory factors and reactive oxygen species production. [ 46 , 47 ] F can be used to prevent and treat cerebral vasospasm post-subarachnoid hemorrhage, [ 48 , 49 ] dementia, [ 50 ] DPN, [ 15 , 17 ] and pulmonary arterial hypertension [ 51 ] in clinical practice. [ 52 ]…”