Stellate Ganglion Block Using Ultrasound Guidance For Treatment Of Post Clipping Cerebral Vasospasm
Stellate Ganglion Block Using Ultrasound Guidance For Treatment Of Post Clipping Cerebral Vasospasm
The present study has been designed to assess the efficacy and safety of Stellate Ganglion
 Block (SGB) in relieving symptomatic cerebral vasospasm following aneurysmal clipping. The
 effect was assessed by both Digital Subtraction Angiography(DSA) and Transcranial Doppler
 (TCD).
Anesthesiologist was informed about the patients (Post clipping for cerebral aneurysm) having
 neurological deterioration (hemiparesis, aphasia, apraxia, hemianopia, or neglect), or a
 decrease of ≥ 2 points on the Glasgow Coma Scale(GCS) and in whom the duration of symptoms
 lasted for at least 1 hour. Anesthesiologist was also informed if increased cerebral blood
 flow velocity was found on routine daily Transcranial Doppler(TCD) evaluation of such
 patients. A cerebral Computed tomography(CT) scan was performed at this time to rule out
 ventricular dilation or any other focal brain lesion explaining the clinical symptoms. In
 such patient Central venous pressure(CVP) was maintained at 8-10 mm of Hg and systolic blood
 pressure was maintained between 160-200 mm Hg (using infusion of vasopressors such as
 phenylephrine or dopamine if required). Oral/ nasogastric nimodipine (60 mg 4 hourly) was
 continued and hemoglobin was maintained at ≥ 10 gm/dl.

 Diagnosis Of Vasospasm By Transcranial Doppler A 2 megahertz (MHz) transcranial Doppler
 ultrasound probe was used to insonate vessels through the temporal acoustic window.
 Extracranial Internal Carotid Artery (ICA) was insonated in the neck using a linear probe of
 8- 13 MHz. Using Transcranial Doppler (TCD) probe, a tracing of waveform of Middle Cerebral
 Artery (MCA) was identified and confirmed using standard criteria. Peak Systolic Velocity and
 Mean Flow Velocity were assessed. Pulsatility Index and Resistivity Index were assessed.
 LINDEGAARD ratio was calculated.

 Diagnosis Of Vasospasm By Digital Subtraction Angiography (DSA) Patients were shifted to
 Digital subtraction Angiography room and an emergency cerebral angiographic study was
 performed using Philips Allura Xper FD20/10 machine. Vasospasm was diagnosed on DSA and the
 vessel diameter was measured at the mid A1 segment of Anterior cerebral artery(ACA) and mid
 M1 segment of Middle Cerebral Artery (MCA). Vasospasm was classified as mild (<25%), moderate
 (25% to 50%), or severe (>50%) with respect to two - dimensional diameter at the mid A1 and
 mid M1 segment of ACA and MCA respectively. Location of vasospasm was classified as
 unilateral vs bilateral, single vessel involvement vs multiple vessel involvement or diffuse
 vasospasm (bilateral with multiple vessel involvement). Parenchymal filling time was
 calculated as the time delay between initiation of contrast injection till the appearance of
 parenchymal blush. Venous sinus filling time was calculated as the time delay between the
 initiation of contrast injection till the appearance of superior sagittal sinus. After
 diagnosis of vasospasm patients were administered ultrasound guided Stellate Ganglion block
 using 10 ml of 0.5% Injection Bupivacaine on the same side of vasospasm or the side
 contralateral to the focal neurological deficit.

 Ultrasound Guided Stellate Ganglion Block - Technique Patients were kept supine with the neck
 in slight hyperextension. Under aseptic conditions, transducer is placed on the surface of
 the neck at the level of Cervical (C6) vertebrae. The internal jugular vein, carotid artery,
 thyroid gland, trachea, C6 vertebrae, transverse process of C6, esophagus, longus colli with
 its covering prevertebral fascia and esophagus are visualized. The transducer was pressed
 between the trachea and the carotid artery to retract the artery laterally as well as to
 position the transducer near the longus colli. A 25-gauge Quincke spinal needle was inserted
 paratracheal towards the middle of the longus colli muscle. The endpoint of the injection was
 the ultrasound image of the tip of the needle as it penetrates the prevertebral fascia
 covering the longus colli muscle. The drug is then injected and spread of drug is visualized
 as distension of prevertebral fascia around the longus colli muscle in real time.

 Post Block Assessment-

 • Development of ipsilateral Horner Syndrome at 5 minutes interval till 30 minutes after
 block to confirm successful Stellate Ganglion Block.

 At thirty minutes after the block the following parameters are assessed:-

 -  Neurological condition (GCS score, motor deficits, aphasia, apraxia, hemianopia or
 neglect). Assessment was done by a blinded neurosurgeon.

 -  Hemodynamic parameters: heart rate, blood pressure

 -  Transcranial doppler measurement of flow velocity in MCA, Pulsatility index(PI),
 Resistivity Index(RI) and LINDEGAARD ratio.

 -  Digital subtraction angiography was repeated to measure diameter of the vessels affected
 by vasospasm, change in grading of vasospasm, any increase in vessel diameter,
 parenchymal filling time and venous sinus filling time. Any increase or decrease in
 parenchymal and venous sinus filling time was noted.

 Block Failure- Block was considered a failure if no signs of Horner's syndrome appeared after
 30 minutes of SGB block.

 Ineffective Stellate ganglion block- Block was considered ineffective after 30 minutes of
 Stellate ganglion block

 -  If there was no neurological improvement

 -  No improvement in Transcranial doppler findings to normal level or no significant change
 in affected vessel diameter, grading of vasospasm, parenchymal filling time and venous
 sinus filling time in second Digital subtraction angiography Rescue Management In case
 of ineffective block, patients were given intra-arterial nimodipine at rate of 0.1
 milligram / minute for a maximum dose of 3 milligram /artery as a rescue measure.

 Following this improvement, these patients were monitored in Intensive care unit(ICU).

 Management Of Patient In Intensive Care Unit

 -  Avoidance of hypotension. Maintenance of Systolic Blood Pressure(SBP) at 160-200 mm of
 Hg using vasopressor {(phenylephrine 2-17microgram/Kg/min) and/or (dopamine-5-10
 microgram/kg/min)}

 -  Avoidance of hypovolemia, maintain Central venous pressure at 8-10 mm of Hg

 -  Maintenance of Hemoglobin ≥ 9gram/decilitre

 -  Oral/nasogastric Nimodipine 60mg 4 hourly. Clinical course of patients was followed.
 Baseline neurological, hemodynamic and TCD parameters were reassessed by the
 anesthesiologist at 30 minutes . Patients with effective block were reassessed for
 neurological status and flow velocity measurements by Transcranial Doppler at 6 hours,
 12 hours, 24 hours, 36 hours and 48 hours after Stellate ganglion block. Patients with
 ineffective block who received rescue management were not reassessed for neurological
 status and flow velocity measurements using Transcranial Doppler at various intervals by
 the anesthesiologist. However the complications occurring in them, the duration of their
 stay in the hospital and the final outcome in the form of discharge or death was noted.

 Complications Of Stellate ganglion block Procedure and drug-related complications were noted.

 Complications During Hospital Stay Complications occurring in the post Stellate Ganglion
 Block period during the entire hospital stay other than those due to the stellate ganglion
 block per se were noted. Duration of hospital stay was also noted.
Inclusion Criteria:

 -  Any patient with post aneurysm clipping having symptomatic vasospasm i:e new onset of
 focal neurological impairment such as hemiparesis, aphasia, apraxia, hemianopia, or
 neglect or decrease of at least 2 points on the Glasgow Coma Scale (GCS) and duration
 of symptoms lasting for at least 1 hour.

 -  Transcranial doppler confirmation of vasospasm by measuring cerebral blood flow
 velocity in MCA and LINDEGAARD ratio.

 -  Cerebral angiographic confirmation of the presence of vasospasm by Digital subtraction
 angiography

 Exclusion Criteria:

 -  New onset of focal neurological deficit or deterioration in the level of consciousness
 due to other causes like re-bleeding, hydrocephalus, cerebral edema, electrolyte
 disorder, infection and seizure.

 -  Patients having an infarct on cerebral tomography.

 -  Patients with clipping of more than one aneurysm.

 -  Patients with bilateral neurological deficits.

 -  History of allergy to local anaesthetic agents.

 -  Refusal of consent.

 -  Deranged coagulation profile.

 -  Patients with pre-existing pupillary changes where assessment of effectiveness of
 Stellate ganglion block will be difficult.

 -  History of allergy to contrast media.

 -  Derangement of renal parameters