From the Guidelines
Vasospasm typically presents with symptoms such as new focal deficits, decreased level of consciousness, confusion, speech difficulties, and headaches, often occurring 3 to 5 days after subarachnoid hemorrhage. The signs and symptoms of vasospasm can vary depending on the affected blood vessels, but in cerebral vasospasm, patients may experience symptoms resembling stroke, including decreased level of consciousness, confusion, and speech difficulties 1. Common signs of cerebral vasospasm include:
- New-onset headaches
- Decreased level of consciousness
- Confusion
- Speech difficulties
- Focal neurological deficits These symptoms can occur with or without obvious signs, and the index of suspicion needs to be higher in poor-grade patients even with subtle changes in neurological examination 1. Monitoring for vasospasm with transcranial Doppler (TCD) technology can be useful, but the literature is inconclusive regarding its sensitivity and specificity, and it requires the establishment of critical thresholds and quality control at each institution 1.
The development of a new focal deficit, unexplained by hydrocephalus or rebleeding, is often the first objective sign of symptomatic vasospasm, and unexplained increases in mean arterial pressure may occur as cerebral arterial autoregulation attempts to improve cerebral circulation to prevent ischemia 1. It is essential to recognize these symptoms promptly, as prolonged vasospasm can lead to tissue damage from inadequate blood supply, and vasospasm appears to account for nearly 50% of the deaths in patients surviving to treatment after subarachnoid hemorrhage 1.
From the FDA Drug Label
The clinical trials demonstrated a favorable effect of nimodipine on the severity of neurological deficits caused by cerebral vasospasm following SAH The signs and symptoms of vasospasm are not explicitly stated in the drug label, but it is mentioned that nimodipine reduces the severity of neurological deficits resulting from vasospasm in patients who have had a recent subarachnoid hemorrhage (SAH) 2.
- The label does mention that the drug has a favorable effect on the severity of these deficits, but it does not provide a list of specific signs and symptoms of vasospasm. Neurological deficits can include a range of symptoms, but the label does not specify which ones are associated with vasospasm.
From the Research
Signs and Symptoms of Vasospasm
The signs and symptoms of vasospasm can be identified through various clinical features. Some of the key characteristics include:
- Worsening headache, although not as severe as the initial headache experienced after subarachnoid hemorrhage 3
- Slight stiffness in the neck 3
- Steady low-grade fever, with no identifiable infectious source 3
- Elevated white blood cell count 3
- Drop in serum sodium concentration 3
- Subtle neurologic signs, such as confusion, which may progress to more severe symptoms like decerebrate posturing and coma if left untreated 3
- Ischemic symptoms, including motor and speech deficits, without other identifiable causes like hydrocephalus, hyponatremia, seizure, intracranial hematoma, or infection 4
Patient Profile
Patients at risk of clinically significant vasospasm are typically adults who have experienced a subarachnoid hemorrhage 4 to 9 days prior, had a poor clinical grade on admission, and showed a thick layer of blood surrounding one or more major cerebral vessels on a CT scan taken 24 to 48 hours after the ictus 3.
Clinical Presentation
The clinical presentation of vasospasm can vary, but it often involves a decline in neurological status, including changes in consciousness, motor function, and speech 4. In some cases, patients may exhibit a faster pulse and slightly higher blood pressure, although the ECG may only show "cerebral T waves" 3.
Diagnostic Considerations
Diagnosing vasospasm typically involves a combination of clinical examination, imaging studies like CT scans, and angiography to detect the presence of vasospasm in the absence of other causes of neurological decline 4, 5.