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LETTER TO THE EDITOR

Stellate Ganglion Block as Alternative to Intrathecal Papaverine in Relieving Vasospasm Due to Subarachnoid Hemorrhage

Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India, prabhakarhemanshu{at}rediffmail.com

To the Editor:

Vasospasm remains a significant cause of morbidity and mortality following subarachnoid hemorrhage (SAH). Recently, the role of cervical sympathetic block has been reported to reverse the delayed ischemic neurologic deficit related to vasospasm following SAH (1). We report two cases in which the use of stellate ganglion block (SGB) relieved vasospasm following SAH.

Intraarterial digital subtraction angiography confirmed the presence of an anterior communicating artery aneurysm (ACOM) in a 44-yr-old woman diagnosed with Hunt and Hess SAH grade III. Ten days later, following aneurysm clipping, she became drowsy and disoriented and developed right sided weakness with motor power of 1/5 in right upper limb. Her Glasgow Coma Score (GCS) was 11 with motor response of 5. Transcranial doppler (TCD) ultrasound revealed vasospasm on the left side. Intrathecal papaverine 10 mg, a routine treatment in our institution, was given with only minimal improvement in the patient’s clinical condition and no change in TCD values. SGB was performed using an anterior paratracheal approach and 10 mL of 0.5% bupivacaine. After 15–20 min, with the onset of SGB all the vessels were again insonated and a significant reduction in the MCA flow velocity was seen (Table 1). At 6 h, the patient showed marked clinical improvement.

Our second patient was a 58-yr-old man diagnosed as Hunt and Hess SAH Grade II. Twelve days after ACOM aneurysm clipping the patient presented with altered sensorium and motor weakness on left side of his body with power of 2/5 in the upper limb. TCD study revealed severe vasospasm of cerebral vessels. SGB was performed and the patient improved both neurologically and clinically and cerebral bloodflow velocity decreased in both the ACA and MCA. Inadvertent administration of intrathecal papaverine 10 mg by the ICU resident had failed to reduce the bloodflow velocity in the cerebral vessels. Repeat SGB had to be given in both patients nearly 24 h after the previous block.

The intracerebral vessels constrict in response to cervical sympathetic stimulation and dilate when these fibers are interrupted (2,3). Anatomically, the stellate ganglion contains cell bodies of the inferior cervical ganglion and the first thoracic sympathetic ganglion. Gupta et al. showed that SGB produces a significant decrease in zero flow pressure, which is a surrogate measure of cerebral vascular tone (4). This seems a logical explanation for improvement in our patients with severe vasospasm. Alternatively, since the SGB followed the use of papaverine in both cases, we cannot rule out an interaction between the two treatments. An additional advantage of SGB is that it can be performed as a bed-side procedure unlike cervical sympathetic block described by Treggiari et al. (1) which requires fluoroscopy. Further trials may be indicated to compare the two techniques in terms of onset of action, efficacy, duration of action, and complications.

REFERENCES

1. Treggiari MM, Romand JA, Martin JB, et al. Cervical sympathetic block to reverse delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage. Stroke 2003;34:961–7.[Abstract/Free Full Text]
2. Tuor UI. Local distribution of the effects of sympathetic stimulation on the cerebral blood flow in the rat. Brain Res 1990;529: 224–31.[Web of Science][Medline]
3. Edvinsson L. Neurogenic mechanisms in the cerebrovascular bed: autonomic nerves, amine receptors and their effects on cerebral blood flow. Acta Physiol Scand (Suppl) 1975;427:1–35.[Medline]
4. Gupta MM, Bithal PK, Dash HH, et al. Effects of stellate ganglion block on cerebral haemodynamics as assessed by transcranial Doppler ultrasonography. Br J Anaesth 2005;9:669–73.

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