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condition and get spasm, that these patients are destined to have a bad outcome no matter what, or there is some link between spasm and bad outcome. The presence of subarachnoid blood correlates with a twofold increased mortality.
Neil Martin also is performing a prospective study that looks at transcranial Dopplers in traumatic head injury. He finds that only 22% of the patients who have traumatic spasms have a good outcome. This is compared to 44% of those patients without spasm that have a good outcome. Virtually no patient who had very severe spasm had a good outcome. If you
have bilateral middle cerebral artery spasms, there are even fewer patients that have good outcome. The group of patients that had bilateral middle cerebral artery vasospasms, basilar spasms and cerebral blood flow below normal, almost none have a good outcome. Most of these patients end up dead or in persistent vegetative states.
The significance of this is that there are 30,000 annual subarachnoid hemorrhages in the United States and 500,000 annual head injuries in the United States. Therefore, the problems with traumatic vasospasms are far more important than the problems that you have with aneurysmal subarachnoid vasospasms. In aneurysmal subarachnoid hemorrhage we have a drug that has been proven in a number of trials to be at least moderately effective in treating aneurysmal subarachnoid hemorrhage vasospasms. This is nimodipine. It can prevent ischemic deficit. Tirilazad may be effective in early trials of aneurysmal subarachnoid hemorrhage and its role in traumatic vasospasms is still in question. Other modalities of therapy in aneurysmal subarachnoid hemorrhage vasospasms are Triple H therapy, Pavrin, and balloon angioplasty. These same techniques may also be effective in trauma.
A recent European study published in the Journal of Neurosurgery in mid 1995 demonstrates that giving nimodipine in traumatic subarachnoid hemorrhages determined on CT scan decreases the unfavorable response from 61% to 44% in the nimodipine treated group. A more recent smaller study done in Germany focused exclusively on traumatic subarachnoid hemorrhage with randomization has also supported the finding that nimodipine decreases the unfavorable response in traumatic subarachnoid hemorrhage.
If you have a traumatic head injury patient who has been stable for several days, and then acutely deteriorates with no CT evidence or suggestion of seizure, there is no metabolic cause and particularly if they have a traumatic subarachnoid hemorrhage, you should be suspicious for cerebral vasospasms and order a transcranial Doppler. If transcranial Doppler is not available, then angiogram should be ordered. If the patient shows vasospasm, then you would be appropriate in treating the patient with Triple H therapy and possibly nimodipine (Martin, et. al., "Journal of Neurotrauma," 1995, October 12:897-901).
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