Download - Vasospasme post-HSA
R Manet(1), S Chatard-Baptiste(2) , S Saleme(2) , L Gergelé(3),
P Gromolard(3), C Nuti(1), FG Barral(2)
(1) Service de neurochirurgie – CHU Saint Etienne
(2) Service de radiologie – CHU Saint Etienne
(3) Département anesthésie-réanimation – CHU Saint Etienne
Cours DES neurochirurgie – 22 avril 2011
• Epidémiologie – pronostic
• Physiopathologie
• Diagnostic
– Clinique
– Monitoring
– Imagerie (S. Chatard-Baptiste)
• Prise en charge
– Traitements médicaux
– Traitements interventionnels (S. Saleme)
• Chronologie
– Précoce (<48h ) : 10% des HSA. Physiopathologie différente
mais morbidité similaire ? (Baldwin, Stroke, 2004);
– Incidence max: J5 – J14;
– Jusqu’à 4 semaines.
• Incidence (Charpentier, Stroke, 1999)
– Vasospasme angiographique : 30 -70% des HSA;
– Vasospasme symptomatique : 17 - 40% des HSA.
(Ischémie Cérébrale Différée: ICD)
• Facteurs de risque:
– Age jeune (Rabb Acta Neurochir 1994; Charpentier, Stroke, 1999 );
– HTA pré-existante (Ohman, J Neurosurg, 1991);
– Tabagisme actif (Lasner, J Neurosurg, 1997);
– Sévérité du tableau clinique initial (Lasner, J Neurosurg, 1997;
Charpentier, Stroke, 1999);
– Insuffisance cardiaque initiale (Friedman, Neurosurgery, 2003);
– Sévérité tomodensitométrique initiale (Claassen, Stroke, 2002);
– Hyperglycémie (Charpentier, Stroke, 1999);
– Nécessité d’une dérivation du LCR (Charpentier, Stroke, 1999).
…QUANTITE DE SANG SOUS-ARACHNOIDIEN
• Facteurs de risque
Clinique initiale & TDM initiale
Claassen, Stroke, 2002
Fisher Infarctus
0 0 %
1 6 %
2 14 %
3 12 %
4 28 %
Hunt&Hess ICD
1 22 %
2 33 %
3 52 %
4 53 %
5 74 %
Greenberg, Handbook Neurosurg, 2010
Complication la plus grave chez les survivants d’une HSA:
• L’ICD est un facteur de risque indépendant de séquellesneurologiques à 6 mois (Charpentier, Stroke, 1999);
• Meilleur pnc neurologique chez patients ne développant pas d’ICD(Dorsch, J Clin Neurosci, 1994);
• 30% de mortalité chez patients avec vasospasme (Dorsch, J Clin
Neurosci, 1994).
Décrit en 1951 Ecker, J Neurosurg, 1951;
Compréhension relativement incomplète;
HSA => hypoperfusion cérébrale:
Dépression hémodynamique immédiate
+/- aggravée secondairement par vasospasme
Tb hémodynamiques & microcirculatoires
* = p < 0,05
Tb hémodynamiques & microcirculatoires
Tb autorégulation / couplage métabolique
PPC AutorégulationCouplage
métabolique
Tb hémodynamiques & microcirculatoires
Tb autorégulation / couplage métabolique
Yundt, J Cereb Blood Flow Metab, 1998
Jaeger, Stroke, 2007
PPC AutorégulationCouplage
métabolique
Ischémie
Tb hémodynamiques & microcirculatoires
Phénomènes microthrombotiques
Aggrégation plaquettaire => micro-infarctus;
Akopov, Cerebrovasc Brain Metab, 1996
Consommation plaquettaire à la phase aigüe d’HAS = facteur prédictif;
indépendant d’ICD Hirashima, J Neurosurg, 2005
Ttt antiplaquettaire => amélioration non significative du pnc neuro.
Dorhout, Stroke, 2008
Tb hémodynamiques & microcirculatoires
Phénomènes microthrombotiques
SAH => Inflammation => Hypercoagulabilité;
Marqueurs plasmatiques de l’ activité thrombine & fibrinolyse corrélés
avec grade HSA et pnc mais pas de corrélation retrouvée entre ces
marqueurs et ICD/infarctus;
Ilveskero, Neurosurgery, 2005
Activité thrombine dans LCR corrélée à infarctus par ICD.
Kasuya, Acta Neurochir, 1998
Inflammation / Stress oxydatif
Inflammatory mediators ( stroke) Potential therapeutic interventions
Stress oxydatif
i NOS neurotoxicité Relargage NO
Chow M, Neurosurgery, 2002
Ng, Neurosurgery,2001
↑Endothéline-I
Vasoconstriction
Prolif endothéliale & m lisse
Inflammation
DIS ?
Pdts dégradation HB COX-2 => PG
Inflammation
Vasoconstriction
Lésion BHE
Bilirubine
Biliverdine
Hème
BOXesVasospasme angiographique
DIS ?
Woszczyk, Acta Neurochir, 2003
NO
ET-I
Péroxydation
lipidique
BOXes
Pilitsis, J Neurosurg, 2002
Clark, J Cereb Blood Flow Metab, 2006
ICD ?
ICD ?
Stress oxydatif: péroxydation lipidique
Levels of CSF F2-IsoPs (specific
marker of lipid peroxidation) levels
during the first 8 days after
surgery (15SAH/10controls).
(A)Non-SAH controls (n=10).
(B)DIND patients (n=3)
Stress oxydatif
Inflammation
↓CBF Stase leucocytaire ↑ infiltration leucocytaire
Lucas, Br J Pharmaco, 2006
Lindsberg, Ann Neurol, 1996
Rothoerl, Cerebrovasc Dis, 2006
Hallenbeck, Stroke, 1986
Dommages locaux Activation microglialeMacrophages
Cytokines
Complément
C3a C5a MAC
Hémolyse
Lésions neuronales
Médiateurs
proinflammatoires
?
Molécules d’adhésion cellulaireI-CAM (ICAM1) V-CAM
Sélectines (P-selectin E-selectin)
Intégrines
Adhésion & infiltration leucocytaire
Mellergård, Neurosurgery, 2011
Inflammation
IL1β
IL6
IL10
Apoptose
P53 / activité caspase
Inhibition P53 chez rat => ↓mortalité ↓rupture BHE ↑pnc neuro
Apoptose
endothéliale
Apoptose
neuronale
Rupture BHE
Cahill, Stroke, 2006
Influx cationique/hydrique passif massif dépassant les capacités de
transport mbr => dépolarisation « galopante » lente (2-5mm/min)
Situation physiologique
Suractivation des transporteurs ATP-dépendants=> conso énergie ++
=> réponse hémodynamique hyperhémique
Normalisation en qlq min (5-15min)
Agression aiguë (HSA)
=> absence de réponse hémodynamique adaptée = ischémie
=> Spreading ischaemia Dreier, Brain, 2009
Durable / auto-entretenue
Cortical spreading depolarization
Cortical spreading depolarization
Dreier, Brain, 2009
Dreier, Brain, 2009
Cortical spreading depolarization
Dreier, Brain, 2009
Apoptose
Tb
hémodynamiques
Stress
oxydatifInflammation
Réduction DSCDécouplage
métaboliqueTb autorégulation
Spreading
depolarization
Souffrance cérébrale
Apoptose
Tb
hémodynamiques
Stress
oxydatifInflammation
Réduction DSCDécouplage
métaboliqueTb autorégulation
Spreading
depolarization
Souffrance cérébrale
Vasospasme post-HSA = Ʃ phénomènes pathologiques complexes
dont l’une des expressions est la réduction de diamètre des
vaisseaux.
Déficit Neurologique
Ischémique Différé
Infarctus
cérébral
Clinique
Dégradation neurologique différée survenant entre J5 et J21:
Tb des fonctions supérieures / Désorientation temporo-spatiale;
Tb de la vigilance;
Ʃd méningé;
Apparition ou aggravation d’un déficit neurologique focal:
- ACA => Ʃd frontal (+/- bilatéral si ACoA);
- ACM => mono/hémiparésie, aphasie, apraxie…
Signes systémiques: hyperthermie, hyponatrémie…
Diagnostique différentiel
• Resaignement;
• Hydrocéphalie;
• Œdème cérébral;
• Epilepsie;
• Tb métaboliques;
• Sepsis;
• …
Monitoring non-invasif
Doppler transcrânien Seiler, J Neurosurg, 1986
VELOCITES MOYENNES VASOSPASME
80 - 120 cm/s Discret
120 - 200 cm/s Modéré
> 200 cm/s Sévère
Augmentation > 50 cm/s/j ATTENTION
Lindegaard (Vm ACM / Vm ACI)
> 3 Vasospasme
> 6 Vasospasme sévère
Lindegaard, Acta Neurochir, 1988
Monitoring non-invasif
Doppler transcrânien
Problèmes: intermittent (=> monitoring continu)
interprétation difficile / opérateur dépendant ++
faible sensibilité (50-67%)
exploration des gros vaisseaux
Monitoring non-invasif
cEEG / qEEG:
Diminution de l’amplitude du signal EEG;
Labar, EEG clin Neurophys, 1991
Diminution relative de l’activité α (6-14 Hz).
Vespa, EEG clin Neurophys, 1997
Diminution du ratio Alpha/Delta (ADR).
Claassen, Clinical Neurophysiology, 2005
Monitoring non-invasif
cEEG / qEEG:
Monitoring non-invasif
cEEG / qEEG:
Monitoring non-invasif
cEEG / qEEG:
♀ 57years. SAH/PCoA. Hunt–Hess grade 4
Post-op (SAH day 2) GCS14, no infarct on CT[…]
SAH day 6: ADR progressively decreased […]
Flow velocities in the right MCA were marginally
elevated (144 cm/s).
SAH day 7: GCS dropped from 14 to 12
=> CTscan + Angiography: vasospasm ++
=> intra-arterial Papaverine/Nicardipine
Monitoring non-invasif
NIRS:
(A) 6 patients (5 WFNS V and 1 WFNS II): only
small changes in CoSO2 (5%) / No vasospasm
on DSA;
(B) 8 patients (5 WFNS V and 3 WFNS II)
showed decreases in CoSO2 by more than 5%
reduction between 5 and 9 days after SAH. 6
exhibited severe vasospasms extending to the
peripheral MCA on DSA. TCD failed to detect in
4 cases.
(A)
(B)
Monitoring invasif
Microdialyse:
15 patients
J Neuroradiol. 2005 Dec;32(5):348-51.
Monitoring invasif
Multimodal
Hourly means ± SD of microdialysis and
PbtO2 measurements 24-hours preceding
CT-scans
- without new infarction (N = 55),
- with new ipsilateral frontal infarction (N = 8)
- with new infarction distant to the monitoring
devices (N = 4)
Biologie
Protéine S100b
LCR Wiesmann, Acta Neurochir, 1997
Plasmatique Takayasu, J Neurosurg, 1985
Autres:
F2-IsoPs LCR Lin, Free Rad Biol Med, 2006
Axe hypothalamo-hypophysaire ? Weant, Neurosurgery, 2008
…
Imagerie
Polygone Angio-imagerie
Micro-circulation (?) Imagerie de perfusion
• Imagerie de premier passage d’un bolus intraveineux d’un agent
exogène non diffusible ( pdc iodé ) dans le réseau capillaire
encéphalique
• Paramètres hémodynamiques cérébraux
• Données qualitatives : cartographies
• Données quantitatives.
TDM perf
TDM perf
TDM perf: cartographie
TDM perf = données quantitatives
Ca bloqueurs: Nimodipine NIMOTOP®
Kazda, Acta Neurochir, 1982 (7 essais randomisés depuis)
→ IVSE / relais Per Os dès que possible
Optimisation rhéologique…
…3H thérapie ? (Hypertension-Hypervolémie-Hémodilution)
Traitements médicaux
3H thérapie (préventive / curative)
• Aucun essai contrôlé randomisé montrant bénéfice.
• Tendance actuelle =
– Normovolémie
– Hypertension contrôlée PAM ≈ 100mmHg - 120mmHg
– Hémodilution est très discutable
– +/- monitoring hémodynamique
Traitements médicaux
• Ca bloqueurs: Nicardipine Haley J Neurosurg 1993
• Antagonistes des rNMDA: SELFOTEL ® Grotta, Stroke, 1995
• Antagonistes des rETA: CLOZANTAN ® Barth, Acta Neurochir, 2007
• Free radical scavengers: FREEDOX® Kassell J Neurosurg 1996
• Nitroprussiate intratéchal Thomas, Stroke, 1999
• Magnésium Veyna, J Neurosurg, 2002
• HBPM Wurm, Clin Neurol Neurosurg, 2004;
• Statines Vergouwen, Stroke, 2010
…
? ? ?
Traitements médicaux
Traitements chirurgicaux
• Epuration des espaces sous-arachnoïdiens (mécanique,
fibrinolytiques, drainage LCR).
• Sympathectomie cervicale Hori, Acta Neurochir, 1979
• Pontages intra-extracrâniens Batjer, Neurosurgery, 1986
• Stimulation du ggl sphénopalatin Yarnitsky, Surg Neurol, 2005
Takahashi, J Neurosurg, 2010
Traitements interventionnels
Traitements endovasculaires
• Angioplastie mécanique;
• Vasodilatation pharmacologique in-situ
• …
Traitements interventionnels
Angioplastie transluminale mécanique
• Zubkov, Acta Neurochir, 1984.
• Muizelaar, J Neurosurg, 1999.
• Rationnel: endommagement vasculaire / destruction des fibres de
collagène et des myocytes Smith, J Vasc Interv Radiol, 2000.
• Pb: complications rares mais généralement dramatiques…
Traitements interventionnels
Papaverine intra-artérielle:
Un des premier produit utilisé.
Nombreuses publications concernant des effets délétères
Mathis, Neuroradiology, 1997
Polin, Neurosurgery, 1998
Smith, Stroke, 2004
…
Traitements interventionnels
Smith, Stroke, 2004
Traitements interventionnels
Papaverine intra-artérielle:
Traitements interventionnels
Ca bloqueurs intra-artériels:
Nimodipine NIMOTOP Biondi, AJNR, 2004
Nicardipine LOXEN Badjatia, AJNR, 2004
Inhibiteur PDE-3 intra-artériels:
Milrinone COROTROPE ® Khajavi, Neurosurgery, 1997
Amrinone INOCOR ® Yoshida, AJNR, 1997
Autres molécules de mecanisme d’action similaire non rapportée dans
le ttt du vasospasme post-HSA:
Enoximone
Imazodan
Piroximone
Traitements interventionnels
Traitements interventionnels
Traitements interventionnels
Contrôle HSA CORO cisternal CORO ia
Histologie tronc basilaire
HES
Immuno
Histo
AMPc
Animaux tués à J7 (après ttt le cas échéant)
Traitements interventionnels
Déficit Neurologique
Ischémique Différé
Infarctus
cérébral
TDMDTCClinique
Pas d’argument
Surveillance
≥ 1 argument
Artériographie
conventionnelle
Echo cœur
Optimisation volémie
Pas de
vasospasmeVasospasme
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