- Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine, Ube, Japan
- The hospitals participating in this survey
The hospitals participating in this survey
DOI:10.4103/2152-7806.81968Copyright: © 2011 Shirao S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Shirao S, Yoneda H, Ishihara H, Kajiwara K, Suzuki M, . A proposed definition of symptomatic vasospasm based on treatment of cerebral vasospasm after subarachnoid hemorrhage in Japan: Consensus 2009, a project of the 25th Spasm Symposium. Surg Neurol Int 09-Jun-2011;2:74
How to cite this URL: Shirao S, Yoneda H, Ishihara H, Kajiwara K, Suzuki M, . A proposed definition of symptomatic vasospasm based on treatment of cerebral vasospasm after subarachnoid hemorrhage in Japan: Consensus 2009, a project of the 25th Spasm Symposium. Surg Neurol Int 09-Jun-2011;2:74. Available from: http://sni.wpengine.com/surgicalint_articles/a-proposed-definition-of-symptomatic-vasospasm-based-on-treatment-of-cerebral-vasospasm-after-subarachnoid-hemorrhage-in-japan-consensus-2009-a-project-of-the-25th-spasm-symposium/
Background:There is a lack of unified information on diagnosis and treatment of cerebral vasospasm (CV) after subarachnoid hemorrhage (SAH) among the hospitals in Japan. Thus, the aim of the study was to define the current practice in this area based on a survey by Japanese neurosurgeons.
Methods:A survey on diagnosis and treatment of CV was sent to 414 hospitals each of which performs >100 neurosurgeries annually.
Results:Responses were received from 240 hospitals (58.0%). Because accurate criteria for diagnosis of symptomatic vasospasm (SVS) were used in only 33.8% of the hospitals, we proposed a clinical definition of SVS that was approved at the 25th Spasm Symposium (Consensus 2009). This definition is simplified as follows: (1) the presence of neurological worsening; (2) no other identifiable cause of neurological worsening; and (3) confirmation of vasospasm by medical examinations. The results also showed that the Fisher CT scale is used differently for patients with ICH or IVH, with 41.3% of cases with ICH/IVH based on SAH that met Fisher criteria classified into Fisher group 1, 2 or 3, and 46.3% classified into Fisher group 4. There were no major differences in prophylactic therapies of CV and therapy for cerebral ischemia among the hospitals. Endovascular treatment for vasospasm was performed in most hospitals (78.7%); however, the criteria differed among the hospitals: (1) angiographic vasospasm and SVS appeared (37.9%), (2) only when aggressive therapy was ineffective (41.4%).
Conclusion:We established a clinical definition of SVS based on the results of this survey (Consensus 2009).
Keywords: Cerebral vasospasm, definition, diagnosis, subarachnoid hemorrhage, survey
The impact of cerebral vasospasm (CV) on the outcome of subarachnoid hemorrhage (SAH) has steadily declined because of medical and surgical advances, but it is still a major cause of morbidity and mortality.[
A survey was sent to 414 hospitals with a neurosurgical department in Japan, at which more than 100 neurosurgeries are performed annually, to evaluate the approach to diagnosis and treatment of CV and to establish the definition of symptomatic vasospasm (SVS) used by most Japanese neurosurgeons. Most patients with SAH in Japan are immediately referred to one of these hospitals since they are designated as emergency centers. The survey included questions on (1) symptoms of SVS, (2) period from development of CV to diagnosis, (3) medical examinations for diagnosis of SVS, (4) diagnostic criteria for SVS, (5) classification of SAH on a CT scan (especially assignment to Fisher group 4), (6) type of cerebrospinal fluid (CSF) drain used during the vasospasm period, (7) prophylactic therapies for CV, (8) therapies for cerebral ischemia caused by CV, (9) type of endovascular treatment for CV, and (10) criteria for an indication of endovascular treatment for CV. Respondents chose from a list of possible symptoms, treatments, and medical examinations, or could give their own choice. For some questions, respondents could make multiple selections from a list of options. Respondents were also given a space for open comments. Responses were collected by the director of each hospital and tabulated by the faculty of the Department of Neurosurgery and Clinical Neuroscience, Yamaguchi University School of Medicine. Responses left blank and cryptic comments were excluded from analysis.
Symptoms of symptomatic vasospasm
A total of 240 hospitals (58.0%) responded to the survey. Symptoms that led to diagnosis of SVS after SAH were (1) focal deficit (97.1%), (2) motor paresis (95%), (3) decline in level of consciousness (94.6%), (4) no other identifiable cause of neurological worsening except CV (80.0%), (5) worsening headache (26.7%), (6) low-grade fever (12.5%), and (7) elevation of blood pressure (12.1%) [
Assessment of symptomatic vasospasm
In the 60 hospitals in which diagnostic criteria for SVS and confirmation by medical examination were used, a diagnosis of SVS required (1) information on the diameter of the artery (91.7%), (2) new low density area (LDA) on CT scans associated with CV (53.3%), (3) measurement of cerebral blood flow (CBF; 26.7%), and (4) TCD (16.7%) [
(a) Required criteria for diagnosis of symptomatic vasospasm. (b) First method of choice to determine the diameter of the cerebrovascular spasm (LDA = low density area; CT = computed tomography; CBF = cerebral blood flow; TCD = transcranial Doppler; 3D-CTA = three-dimensional CT angiography; MRA = MR angiography)
Fisher CT scale
The classification on the Fisher CT scale[
Classification of patients with SAH and ICH or IVH on the Fisher CT scale: (A) all patients with ICH or IVH classified as Fisher group 4; (B) patients with ICH or IVH classified as Fisher group 1, 2 or 3 with ICH/IVH based on SAH that met the Fisher criteria; (C) patients with no SAH and ICH or IVH classified as Fisher group 4; (D) other classifications (SAH = subarachnoid hemorrhage; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage)
Surgical treatment modality and drainage system
The first choice methods for obliteration of the aneurysm were (1) neck clipping (42.5%), (2) coil embolization (8.3%), and (3) neck clipping or coil embolization based on aneurysm features and progression of neurological and medical conditions (49.2%). In most hospitals, the CSF drain was placed during the vasospasm period after neck clipping (89.5%) and coil embolization (83.3%). The CSF drains placed after neck clipping were (1) a cisternal drain (86.8%), (2) a lumbar drain (34.2%), and (3) an external ventricular drain (31.6%). The CSF drains placed after coil embolization were (1) a lumbar drain (94.8%), (2) an external ventricular drain (7.9%), and (3) a cisternal drain (1.8%). Cisternal irrigation therapy was performed in 23.1% of hospitals after neck clipping and in 11.2% after coil embolization.
Prophylactic therapies for cerebral vasospasm
The prophylactic therapies for CV in most hospitals were (1) volume control (99.6%), (2) treatment for cerebral salt wasting syndrome (CSWS; 96.3%),[
(a) Therapies for cerebral ischemia. (b) Criteria for indication of treatment for cerebral ischemia caused by cerebral vasospasm: (A) angiographic vasospasm presented in large extraparenchymal arteries with or without symptomatic vasospasm; (B) appearance of symptomatic vasospasm; (C) new LDA on CT scans associated with cerebral vasospasm; (D) other
Therapies for cerebral ischemia
The main therapies for cerebral ischemia caused by CV were (1) intravenous administration of edaravone, a free radical scavenger (60.0%),[
Endovascular treatment for vasospasm
Endovascular treatment for vasospasm was performed in most hospitals (78.7%). Treatment modalities or vasodilatory agents included (1) intra-arterial injection of fasudil hydrochloride (84.1%),[
(a) Endovascular treatment for vasospasm. (b) Criteria for indication of endovascular treatment for vasospasm: (A) angiographic vasospasm in the large extraparenchymal arteries with or without symptomatic vasospasm; (B) angiographic vasospasm in the large extraparenchymal arteries with symptomatic vasospasm; (C) only when aggressive therapy for angiographic and symptomatic vasospasm was ineffective; (D) other
It is clear from the results of this survey that there is no consensus among Japanese hospitals on the criteria for diagnosis of SVS. Since standardized care for CV requires accurate diagnostic criteria for SVS, we proposed a clinical definition of SVS based on the results of this survey at the 25th Spasm Symposium (Stroke 2009) in Japan. This definition (Consensus 2009) was approved and is as follows: (1) the presence of neurological worsening including focal deficit, decline in level of consciousness, and motor paresis; (2) no other identifiable cause (intracranial disorder and systemic complication) of neurological worsening; and (3) confirmation of vasospasm by medical examinations including evidence of vasospasm on cerebral angiography, 3D-CTA, and MRA; new LDA on CT scans associated with CV; reduced CBF; and elevation of mean blood flow velocity in the cerebral arteries using TCD ultrasonography. Symptoms of worsening headache, low-grade fever, and elevation of blood pressure are included as reference information since these are not necessarily ischemic symptoms. For patients in whom subtle changes are difficult to detect in a neurological examination, we recommend using a medical examination (with diffusion- and perfusion-weighted MRI, if possible) to identify patients with an ischemic condition. In addition, we are planning to perform a further prospective study of the incidence of SVS in SAH patients in Japan based on the Consensus 2009 criteria.
The results of this survey indicated no major differences in prophylactic treatment of CV among the hospitals. Treatment including volume control, blood pressure control, treatment of CSWS, and intravenous administration of fasudil hydrochloride were common. In a placebo-controlled, double-blind trial,[
The main therapies for cerebral ischemia caused by CV included intensive therapies such as intravenous administration of edaravone, a free radical scavenger,[
Cisternal drainage has been used in Japan to eliminate residual clot after surgical removal since the late 1980s.[
The Fisher CT scale[
Our survey indicates that endovascular treatment for vasospasm was performed safely and that intra-arterial injection of fasudil hydrochloride was the most common treatment modality and vasodilatory agent. Endovascular treatment is recommended in the Guidelines for the Management of CV (Class II b, Level of Evidence B), but the criteria used to indicate endovascular treatment for vasospasm are not well defined.[
In this study, we established a clinical definition of SVS, which we refer to as Consensus 2009. In Japan, most hospitals provide similar treatment for CV, but with significant differences in Fisher group criteria for patients with ICH or IVH, and in the criteria used to indicate endovascular treatment for vasospasm. This survey has several limitations. First, although the respondents were given space for open comments, they were mainly constrained by the questionnaire design (respondents chose from a list of possible choices). Second, although the response rate of 58.0% was acceptable compared to other studies,[
We thank the members of the Organizers of 25th Spasm Symposium (Stroke 2009) who made the project possible: Akira Ogawa, M.D., Akira Satoh, M.D., Hidetoshi Kasuya, M.D., Hiroki Ohkuma, M.D., Hirotoshi Sano, M.D., Hiroyuki Kinouchi, M.D., Isao Date, M.D., Izumi Nagata, M.D., Jun-ichiro Hamada, M.D., Kazuo Yamada, M.D., Kenji Kanamaru, M.D., Kiyotaka Fujii, M.D., Koji Osuka, M.D., Kuniaki Ogasawara, M.D., Nobuhito Saito, M.D., Nobuo Hashimoto, M.D., Nobuyuki Yasui, M.D., Phyo Kim, M.D., Shigeru Nishizawa, M.D., Shinji Nagahiro, M.D., Shunro Endo, M.D., Tadayoshi Nakagomi, M.D., Takashi Watanabe, M.D., Tatsuya Ishikawa, M.D., Tatsuya Sasaki, M.D., Teiji Tominaga, M.D., Tomio Sasaki, M.D., Tomokatsu Hori, M.D., Toru Matsui, M.D., Toshisuke Sakaki, M.D., Yoichi Katayama, M.D., Yoko Kato, M.D., Yoshiaki Shiokawa, M.D., Yutaka Hirashima, M.D., and Waro Taki, M.D. We also thank the members of the 25th Spasm Symposium (Stroke 2009) for providing data.
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