Decrease of blood flow velocity in the middle cerebral artery after stellate ganglion block following aneurysmal subarachnoid hemorrhage: a potential vasospasm treatment?

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  • 1 Neurosurgical Clinic and
  • 2 Department of Anesthesiology and Intensive Care Medicine, Klinikum Stuttgart, Germany;
  • 3 Department of Anesthesiology, Kantonsspital Münsterlingen, Switzerland;
  • 4 University of Heidelberg;
  • 5 Neuroradiological Clinic, Klinikum Stuttgart; and
  • 6 Department of Anesthesiology and Intensive Care, Philipps-University Marburg, Germany
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OBJECTIVE

Cerebral vasospasm (CV) is a delayed, sustained contraction of the cerebral arteries that tends to occur 3–14 days after aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured aneurysm. Vasospasm potentially leads to delayed cerebral ischemia, and despite medical treatment, 1 of 3 patients suffer a persistent neurological deficit. Bedside transcranial Doppler (TCD) ultrasonography is used to indirectly detect CV through recognition of an increase in cerebral blood flow velocity (CBFV). The present study aimed to use TCD ultrasonography to monitor how CBFV changes on both the ipsi- and contralateral sides of the brain in the first 24 hours after patients have received a stellate ganglion block (SGB) to treat CV that persists despite maximum standard therapy.

METHODS

The data were culled from records of patients treated between 2013 and 2017. Patients were included if an SGB was administered following aSAH, whose CBFV was ≥ 120 cm/sec and who had either a focal neurological deficit or reduced consciousness despite having received medical treatment and blood pressure management. The SGB was performed on the side where the highest CBFV had been recorded with 8–10 ml ropivacaine 0.2%. The patient’s CBFV was reassessed after 2 and 24 hours.

RESULTS

Thirty-seven patients (male/female ratio 18:19), age 17–70 years (mean age 49.9 ± 11.1), who harbored 13 clipped and 22 coiled aneurysms (1 patient received both a coil and a clip, and 3 patients had 3 untreated aneurysms) had at least one SGB. Patients received up to 4 SGBs, and thus the study comprised a total of 76 SGBs.

After the first SGB, CBFV decreased in 80.5% of patients after 2 hours, from a mean of 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001), and it further decreased in 63.4% after 24 hours to 137.2 ± 38.2 cm/sec (p = 0.007). A similar significant effect was found for the subsequent SGB. Adding clonidine showed no significant effect on either the onset or the duration of the SGB. Contralateral middle cerebral artery (MCA) blood flow was not reduced by the SGB.

CONCLUSIONS

To the authors’ knowledge, this is the largest study on the effects of administering an SGB to aSAH patients after aneurysm rupture. The data showed a significant reduction in ipsilateral CBFV (MCA 20.5%) after SGB, lasting in about two-thirds of cases for over 24 hours with no major complications resulting from the SGB.

ABBREVIATIONS aSAH = aneurysmal subarachnoid hemorrhage; CBFV = cerebral blood flow velocity; CV = cerebral vasospasm; DCI = delayed cerebral ischemia; GOS = Glasgow Outcome Scale; IAVT = intraarterial vasodilator infusion therapy; MAP = mean arterial pressure; MCA = middle cerebral artery; SGB = stellate ganglion block; TCD = transcranial Doppler; WFNS = World Federation of Neurosurgical Societies.

Supplementary Materials

    • Supplemental Figure 1 and Table 1 (PDF 425 KB)

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Contributor Notes

Correspondence Christopher Wendel: Neurosurgical Clinic, Klinikum Stuttgart, Germany. c.wendel@klinikum-stuttgart.de.

INCLUDE WHEN CITING Published online August 9, 2019; DOI: 10.3171/2019.5.JNS182890.

Disclosures Dr. Henkes reports being a stockholder in, a patent holder with, and a consultant for phenox GmbH.

  • 1

    Abruzzo T, Moran C, Blackham KA, Eskey CJ, Lev R, Meyers P, : Invasive interventional management of post-hemorrhagic cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 4:169177, 2012

    • Search Google Scholar
    • Export Citation
  • 2

    Achrol AS, Steinberg GK: Personalized medicine in cerebrovascular neurosurgery: precision neurosurgical management of cerebral aneurysms and subarachnoid hemorrhage. Front Surg 3:34, 2016

    • Search Google Scholar
    • Export Citation
  • 3

    Arakawa Y, Kikuta K, Hojo M, Goto Y, Ishii A, Yamagata S: Milrinone for the treatment of cerebral vasospasm after subarachnoid hemorrhage: report of seven cases. Neurosurgery 48:723730, 2001

    • Search Google Scholar
    • Export Citation
  • 4

    Bindra A, Prabhakar H, Singh GP: Stellate ganglion block for relieving vasospasms after coil embolization of basilar tip aneurysms. J Neurosurg Anesthesiol 23:379, 2011

    • Search Google Scholar
    • Export Citation
  • 5

    Brisman JL, Song JK, Newell DW: Cerebral aneurysms. N Engl J Med 355:928939, 2006

  • 6

    Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, : Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 43:17111737, 2012

    • Search Google Scholar
    • Export Citation
  • 7

    D’Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, : Transcranial Doppler ultrasonography: from methodology to major clinical applications. World J Cardiol 8:383400, 2016

    • Search Google Scholar
    • Export Citation
  • 8

    Francoeur CL, Mayer SA: Management of delayed cerebral ischemia after subarachnoid hemorrhage. Crit Care 20:277, 2016

  • 9

    Fraticelli AT, Cholley BP, Losser MR, Saint Maurice JP, Payen D: Milrinone for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 39:893898, 2008

    • Search Google Scholar
    • Export Citation
  • 10

    Frontera JA, Fernandez A, Schmidt JM, Claassen J, Wartenberg KE, Badjatia N, : Defining vasospasm after subarachnoid hemorrhage: what is the most clinically relevant definition? Stroke 40:19631968, 2009

    • Search Google Scholar
    • Export Citation
  • 11

    Gupta MM, Bithal PK, Dash HH, Chaturvedi A, Mahajan RP: Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography. Br J Anaesth 95:669673, 2005

    • Search Google Scholar
    • Export Citation
  • 12

    Hughes JD, Bond KM, Mekary RA, Dewan MC, Rattani A, Baticulon R, : Estimating the global incidence of aneurysmal subarachnoid hemorrhage: a systematic review for central nervous system vascular lesions and meta-analysis of ruptured aneurysms. World Neurosurg 115:430447, 447.e1–447.e7, 2018

    • Search Google Scholar
    • Export Citation
  • 13

    Jain V, Rath GP, Dash HH, Bithal PK, Chouhan RS, Suri A: Stellate ganglion block for treatment of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage—a preliminary study. J Anaesthesiol Clin Pharmacol 27:516521, 2011

    • Search Google Scholar
    • Export Citation
  • 14

    Kakuyama M, Toda H, Osawa M, Fukuda K: The bilateral effect of stellate ganglion block on the facial skin blood flow. Reg Anesth Pain Med 25:389392, 2000

    • Search Google Scholar
    • Export Citation
  • 15

    Kim EM, Yoon KB, Lee JH, Yoon DM, Kim DH: The effect of oxygen administration on regional cerebral oxygen saturation after stellate ganglion block on the non-blocked side. Pain Physician 16:117124, 2013

    • Search Google Scholar
    • Export Citation
  • 16

    Lysakowski C, Walder B, Costanza MC, Tramèr MR: Transcranial Doppler versus angiography in patients with vasospasm due to a ruptured cerebral aneurysm: a systematic review. Stroke 32:22922298, 2001

    • Search Google Scholar
    • Export Citation
  • 17

    Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N: Continuous local intra-arterial nimodipine administration in severe symptomatic vasospasm after subarachnoid hemorrhage. Neurosurgery 68:15411547, 2011

    • Search Google Scholar
    • Export Citation
  • 18

    Naidu RK: A review of the stellate ganglion block/cervical sympathetic block on the prevention and therapy of cerebral vasospasm after subarachnoid hemorrhage. ICU Dir 4:161165, 2013

    • Search Google Scholar
    • Export Citation
  • 19

    Nie Y, Song R, Chen W, Qin Z, Zhang J, Tang J: Effects of stellate ganglion block on cerebrovascular vasodilation in elderly patients and patients with subarachnoid haemorrhage. Br J Anaesth 117:131132, 2016

    • Search Google Scholar
    • Export Citation
  • 20

    Pickard JD, Murray GD, Illingworth R, Shaw MD, Teasdale GM, Foy PM, : Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ 298:636642, 1989

    • Search Google Scholar
    • Export Citation
  • 21

    Pöpping DM, Elia N, Marret E, Wenk M, Tramèr MR: Clonidine as an adjuvant to local anesthetics for peripheral nerve and plexus blocks: a meta-analysis of randomized trials. Anesthesiology 111:406415, 2009

    • Search Google Scholar
    • Export Citation
  • 22

    Prabhakar H, Jain V, Rath GP, Bithal PK, Dash HH: Stellate ganglion block as alternative to intrathecal papaverine in relieving vasospasm due to subarachnoid hemorrhage. Anesth Analg 104:13111312, 2007

    • Search Google Scholar
    • Export Citation
  • 23

    Rohan B, Singh PY, Gurjeet K: Addition of clonidine or lignocaine to ropivacaine for supraclavicular brachial plexus block: a comparative study. Singapore Med J 55:229232, 2014

    • Search Google Scholar
    • Export Citation
  • 24

    Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KTS: Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm. Br J Anaesth 109:315329, 2012

    • Search Google Scholar
    • Export Citation
  • 25

    Schmidt JM, Wartenberg KE, Fernandez A, Claassen J, Rincon F, Ostapkovich ND, : Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage. J Neurosurg 109:10521059, 2008

    • Search Google Scholar
    • Export Citation
  • 26

    Shankar JJS, dos Santos MP, Deus-Silva L, Lum C: Angiographic evaluation of the effect of intra-arterial milrinone therapy in patients with vasospasm from aneurysmal subarachnoid hemorrhage. Neuroradiology 53:123128, 2011

    • Search Google Scholar
    • Export Citation
  • 27

    Song JG, Hwang GS, Lee EH, Leem JG, Lee C, Park PH, : Effects of bilateral stellate ganglion block on autonomic cardiovascular regulation. Circ J 73:19091913, 2009

    • Search Google Scholar
    • Export Citation
  • 28

    Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G: European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 35:93112, 2013

    • Search Google Scholar
    • Export Citation
  • 29

    Suarez JI, Tarr RW, Selman WR: Aneurysmal subarachnoid hemorrhage. N Engl J Med 354:387396, 2006

  • 30

    Treggiari MM, Romand JA, Martin JB, Reverdin A, Rüfenacht DA, de Tribolet N: Cervical sympathetic block to reverse delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage. Stroke 34:961967, 2003

    • Search Google Scholar
    • Export Citation
  • 31

    Velat GJ, Kimball MM, Mocco JD, Hoh BL: Vasospasm after aneurysmal subarachnoid hemorrhage: review of randomized controlled trials and meta-analyses in the literature. World Neurosurg 76:446454, 2011

    • Search Google Scholar
    • Export Citation
  • 32

    Veldeman M, Höllig A, Clusmann H, Stevanovic A, Rossaint R, Coburn M: Delayed cerebral ischaemia prevention and treatment after aneurysmal subarachnoid haemorrhage: a systematic review. Br J Anaesth 117:1740, 2016

    • Search Google Scholar
    • Export Citation
  • 33

    Willie CK, Tzeng YC, Fisher JA, Ainslie PN: Integrative regulation of human brain blood flow. J Physiol 592:841859, 2014

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