Early cervical sympathectomy for management of cerebral vasospasm in traumatic head injuries a cross sectional prospective study

Early cervical sympathectomy for management of cerebral vasospasm in traumatic head injuries a cross sectional prospective study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Early cervical sympathectomy for management of cerebral vasospasm in traumatic head injuries a cross sectional prospective study Ahmed Abdelmabood, Ahmed Elsaied Abdelrahman, Medhat Ibraheem, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7309323/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Head trauma is a leading cause for both death and disability among patients (3),. It can result in a wide range of pathological conditions (7), with cerebral vasospasm being a frequently encountered complication (1,8), Several treatment approaches are employed to manage cerebral vasospasm (6), cervical symoathectomy in the form of stellate ganglion block is one of these methods (11) Aim of the study : assessment of the effect of cervical sympathectomy on the reduction of cerebral vasospasm primarily and secondarily the impact of this reduction on patient follow-up and prognosis. Methods : 30 adult patients with isolated head trauma injury had a bilateral ultrasound-guided stellate block with 8 ml 0.5% bupivacaine and 40 mg of betamethasone. Patient follow-up included hemodynamics, Transcranial-Doppler for middle cerebral artery, basilar artery, GCS, and improvement and motor deficit after one week of follow-up. Results : we found that cerebral vasospasm improved, MCA measurements improved in comparison to baseline at 1 ST day, 2 ND day, and after one week, (P value < 0.001). GCS was better in comparison to baseline after one week (P value < 0.001). MBP was unaffected in comparison to the baseline, after 15, 30, and 60 minutes. Conclusion : Early cervical sympathectomy is an efficient method for the reduction of cerebrovascular spasm after traumatic brain injury. Ckinical trials registry number NCT05182619, registry date 10/12/2021 stellate block cerebral blood flow neurological improvement Figures Figure 1 Introduction Cerebral vasospasm is a major complication following traumatic head injury (SAH), contributing significantly to reduced cerebral perfusion and brain ischemia (DCI), neurological deterioration, and increased morbidity and mortality [ 1 , 2 ]. The current standard of care includes hemodynamic augmentation, calcium channel blockers (such as Nimodipine), and, in selected cases, endovascular interventions [ 3 , 4 ]. Despite these interventions, treatment-refractory vasospasm continues to challenge clinicians and is associated with poor outcomes [ 5 ]. In recent years, stellate ganglion block (SGB) has gained attention as an adjuvant therapy in managing cerebral vasospasm. This sympathetic ganglion which is formed by the fusion of the inferior cervical and first thoracic sympathetic ganglia plays a key role in the regulation of cerebral vasculature [ 6 , 7 ]. Blocking this structure has been shown to produce regional vasodilation, increase cerebral blood flow, and reduce cerebrovascular resistance [ 8 – 10 ]. Several case reports and clinical studies have documented the effectiveness of SGB in improving cerebral perfusion in patients with refractory vasospasm, suggesting a promising therapeutic role [ 11 – 13 ]. Moreover, the procedure is relatively safe when performed under image guidance and may offer a minimally invasive alternative or supplement to traditional vasospasm therapies [ 14 ]. This article reviews the physiological rationale, technique, current clinical evidence, and potential role of SGB in the management of cerebral vasospasm following SAH, with a focus on its mechanisms of action and future research directions. Methods This study is a prospective cross-sectional study done in the Sohag University hospitals' intensive care unit during the period from 2021 to 2023 Following approval from the local Research Ethics Committee of the Faculty of Medicine at Sohag University, informed written consent was obtained from a first-degree relative of each patient for participation in the study. The research protocol was reviewed and aligned with the ethical principles outlined in the Declaration of Helsinki for medical research involving human subjects. Ethical committee approval number ( soh-Med-21-12-19) Clinical trials registry number (NCT05182619) 30 adult patients underwent bilateral ultrasound-guided stellate ganglion block with 8 ml 0. 5% bupivacaine added to it 40 mg of betamethasone Inclusion criteria patients older than 18 years with isolated traumatic brain injury and with evidence of cerebral vasospasm detected by transcranial Doppler > 120cm/s in the middle cerebral artery. Exclusion criteria : Severe hypotension (mean ABP less than 70 mmHg) severe systemic illness including cardiac pulmonary failure or hepatic or renal impairment hypersensitivity to one of the used drugs impaired blood coagulation disturbed neck anatomy by tumors or a huge thyroid gland Diabetic patients or patients with a history of vascular insufficiency On arrival to the emergency unit, all patients had first aid management according to their general condition, CT brain was done, GCS was assessed and recorded in the patient admission sheet, full monitoring by pulse oximetry, NIBP, ECG, was conducted and baseline readings were recorded. CT brain data were recorded on arrival for pathology classification and staging. The method of Stellate ganglion block: Patients were supine with their heads centered; a pillow was placed below the neck and shoulders if needed for optimal alignment. After performing aseptic skin preparation, a linear ultrasound probe (10 MHz) was placed on the neck to get a cross-sectional view of the anatomical structures. The transverse process of the C6 vertebra was identified first. The ultrasound probe was positioned at a 45-degree angle to the neck’s sagittal plane and adjusted as necessary to clearly visualize both the common carotid artery and the stellate ganglion. An echogenic blunt-tip ultrasound-guided 22-gauge needle was introduced laterally to the probe to avoid injury to the jugular vein and nearby neurovascular structures. The needle was advanced under continuous ultrasound guidance toward the stellate ganglion, located beneath the common carotid artery. Once the target was reached, a solution of 8 ml of 0.5% bupivacaine combined with 40 mg of betamethasone was injected. The needle was adjusted to ensure uniform distribution of the injectate. Successful blockade was confirmed by the appearance of the manifestations of Horner’s syndrome on the injected side, including miosis, upper eye lid drop, enophthalmos, hyperemia at the conjunctiva, and facial flushing without sweating. Simultaneously, potential complications such as hematoma, pneumothorax, inadvertent epidural or subarachnoid block, hoarseness, esophageal trauma, and thyroid gland injury were monitored and documented. Patient follow-up and monitoring: Continuous monitoring of vital signs before and after initiation of the therapeutic procedure (pulse oximetry, ECG,, NIBP) and data was recorded continuously for the first thirty minutes from the start of the procedure, Special care was given to the early signs of phrenic nerve block including tachypnea respiratory distress, abdominal breathing as mechanical ventilation may be necessary. Transcranial Doppler was done for all patients after admission to ICU and stabilization, middle cerebral artery was assessed through the temporal window and the basilar artery was assessed through the occipital window, Doppler scan was done by an efficient radiologist, trans-cranial Doppler was done before intervention, at first day after intervention (12hs) post intervention, second day, and then after one week. Statistical analysis Statistical analysis was done using SPSS version 26 (IBM Corp., Chicago, IL, USA). Quantitative data were expressed as mean ± standard deviation (SD) and compared between the two groups using the unpaired Student’s t-test. Categorical data were expressed as counts and proportions, and comparisons were performed using the Chi-square test. Statistical significance was defined as a two-tailed p-value less than 0.05." Sample size calculation: The sample size was calculated for a one-group, pre-post comparison of cerebral blood flow velocity (CBFV) before and after Stellate Ganglion Block (SGB). Assuming a mean difference of 20 cm/s and a standard deviation of differences of 25 cm/s, with alpha = 0.05 and power = 80%, the required sample size was calculated to be 13 patients. To account for potential dropouts or incomplete measurements, we increased the sample size by 15%, resulting in a final total of 15 patients. Results As illustrated in flow chart we started with 40 pts, 5 patients refused participation, 5 pts didn’t meet inclusion criteria then 30 pts were enrolled. Figure (1): flow chart of patients participation As shown in Table (1) we can find that the majority of cases that had cerebral vasospasm are patients with subarachnoid hemorrhage. Table 1 Patient characteristics and brain pathology of the studied group. Brain pathology SAH 25 (83.33%) subdural h 1 (3.33%) brain contusions 2 (6.67%) axonal damage 1 (3.33%) There was no difference in oxygen saturation or heart rate before and after intervention. Table (2): Oxygen saturation. Heart rate follow-up after intervention. baseline 15 ms after intervention P value Spo2 in%)percentage 92.73 ± 2.13 93.23 ± 1.65 0.314 HR (beat/minute) 98.57 ± 9.91 94.37 ± 6.54 0.058 Data are expressed in form of mean ± SD *: Significant as P value ≤ 0.05. SpO2: Peripheral capillary oxygen saturation, HR: heart rate. MBP was insignificantly different in comparison to baseline at 15 m, 30 m, and 60 ms. Table (3): Follow-up of MBP of the studied group.(mmHg) baseline 90.4 ± 12.62 15 m 88.6 ± 10.16 30m 88.23 ± 9.9 60m 88.9 ± 10.8 P value P1 0.5448 P2 0.4551 P3 0.6224 . MBP: Mean blood pressure, p-value is insignificant as > 0.05 Middle cerebral artery measurements showed significantly different reduction on the 1st day, 2nd day, and one week in comparison to the baseline (P value < 0.001). Table (4): Middle cerebral Doppler measurements follow-up of the studied group.(cm/second) Baseline 155.33 ± 9.55 1st day 134.67 ± 11.44 2nd day 130.67 ± 12.58 One week 133.97 ± 14.83 P value P1 < 0.001* P2 < 0.001* P3 < 0.001* *: Significant as P value ≤ 0.05. P1: P value between baseline and 1st day, P2: P value between baseline and 2nd day, P3: P value between baseline and one week. Basilar artery measurements showed a significantly different reduction on the 1st day, 2nd day, and one week in comparison to the baseline (P value < 0.001). Table (5): Basilar artery measurements of the studied groups in (cm/second). Group S (n = 30) Baseline 91.33 ± 5.71 1st day 84.33 ± 5.83 2nd day 81.33 ± 4.34 One week 78.5 ± 4.58 P value P1 < 0.001* P2 < 0.001* P3 < 0.001* *: Significant as P value ≤ 0.05. P1: P value between baseline and 1st day, P2: P value between baseline and 2nd day, P3: P value between baseline and one week. There was a clinical improvement in GCS after one week in comparison to the baseline (P value < 0.001). Table (6): GCS at baseline and after one month of the studied group. Baseline 11.47 ± 1.25 After one week 14.5 ± 0.5 P value < 0.001* RT hemiplegia patients with clinical improvement after one week was (83%) while LT hemiplegia patients with clinical improvement after one week was (4%) Table (7): Neurological evaluation after one week of the studied group. Baseline number Improved pts percentage Rt motor deficit 12 10 83.3% Lt motor deficit 10 4 40% Discussion As regards patients' diagnosis before scanning for cerebral vasospasm, we can find that the majority of cases had subarachnoid hemorrhage complicated by 2ry cerebral vasospasm (83.3%) of patients We can find that vital signs including heart rate, mean arterial blood pressure, and oxygen saturation were not affected by the intervention. As regards transcranial Doppler follow-up at the middle cerebral artery Doppler, there was a significant reduction in cerebral blood velocity meaning a reduction in cerebral vasospasm after the intervention at 1st day, 2nd day, and one week in comparison to baseline. Similar results could be found in the comparison of measurements at the basilar artery compared to baseline, there was a significant reduction on the 1st day, 2nd day, and one week in comparison to baseline. These findings align with those reported by Wu et al. (2023) [ 16 ], who conducted a study utilizing transcranial Doppler (TCD) ultrasonography to evaluate changes in cerebral blood flow velocity (CBFV) on both the ipsilateral and contralateral sides of the brain within the first 24 hours following stellate ganglion block (SGB) administration in patients with cerebral vasospasm (CV) unresponsive to maximal standard treatment. A total of 76 SGB procedures were performed, with some patients receiving up to four blocks., A total of 76 stellate ganglion blocks (SGBs) were performed in the study. Two hours following the initial SGB, cerebral blood flow velocity (CBFV) showed a significant reduction in 80.5% of patients, decreasing from a mean of 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001). Additionally, after 24 hours, 63.4% of patients exhibited a further decline in CBFV, reaching 137.2 ± 38.2 cm/sec (p = 0.007), indicating a statistically significant change.. A comparable effect was observed with subsequent stellate ganglion blocks. Notably, there was no reduction in blood flow within the contralateral middle cerebral artery (MCA) following SGB. The findings revealed a significant decrease in ipsilateral CBFV within the MCA—approximately 20.5%—after the procedure, with this effect persisting for more than 24 hours in nearly two-thirds of patients. Importantly, no major complications were reported as a result of the SGB. Also, Christopher Wendel et al.(2019) [ 15 ] examined the impact of stellate ganglion block on cerebral vasospasm following subarachnoid hemorrhage. They performed SGB on the side where the highest CBFV had been recorded with 8–10 ml of ropivacaine 0.2%. The patient’s CBFV was remeasured after 2 and 24 hours. Within two hours of the initial stellate ganglion block, a reduction in cerebral blood flow velocity (CBFV) was observed in 80.5% of patients, with the mean value decreasing from 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001). After 24 hours, 63.4% of patients continued to show a decline in CBFV, reaching an average of 137.2 ± 38.2 cm/sec (p = 0.007). Regarding the comparison of the patient prognosis and Glasgow coma scale GCS improvement in both groups there was significant improvement in GCS after the intervention, As regards comparison at the level of clinical improvement of motor deficit, (83.3%) of right-sided hemiplegia clinically improved wile (40%) of lt sided hemiplegia patients clinically improved This finding is consistent with the results reported by Davis et al (2021) (17) A stellate ganglion block (SGB) was administered to a patient diagnosed with severe reversible cerebral vasoconstriction syndrome, with transcranial Doppler used to monitor cerebral vasospasm. Improvement in cerebral blood flow was associated with a progressive resolution of acute neurological symptoms, including motor deficits, and the patient reported the absence of headache the next day. Bilateral stellate ganglion block was done ultrasound-guided with no documented complications in 30 patients. Contrary to our results, Goel et al., (2019) (18) reported complications of SGB that are rare but can be life-threatening. The reported incidence of severe complications was 1.7 per 1,000 stellate ganglion blocks, based on a total of 45,000 procedures, with most adverse events being neurological, such as convulsions, Of these cases, six were attributed to high subarachnoid block, three to high epidural blockade, nine to pneumothorax, and two were due to allergic reactions. The detection of these complications was likely facilitated by the large sample size, in contrast to our study, which involved a relatively smaller cohort. Conclusion Early stellate ganglion block is an efficient method for the reduction of cerebral vasospasm that can improve outcome, reduce morbidity, and provide clinical improvement in neurological deficit resulting from post-traumatic cerebral vasospasm. Declarations Declaration of interests ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethical approval and consent to participate: This report complies with regional and institutional ethical guidelines and with declaration of Helsinki. A written informed consent was obtained from the first degree relative of all our cases before participation in the research Ethical committee approval number ( soh-Med-21-12-19) Clinical trials registry number (NCT05182619), registration date 10/12/2021 Submission declaration and verification: All authors of this paper have approved the final version to be submitted; The contents of this manuscript have not been copyrighted or published previously nor under consideration for publication elsewhere; The contents of this manuscript will not be copyrighted, submitted, or published elsewhere, while acceptance by the Journal is under consideration; There are no directly related manuscripts or abstracts, published or unpublished, by any authors of this paper. Consent of publication : Not Applicable Availability of data and material: Any data or materials related to the case are readily available for revision Competing interests: The authors declare that they have no competing interests Funding: none Acknowledgements: none References Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke. 2012;43(6):1711–37. 10.1161/STR.0b013e3182587839 . Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet. 2017;389(10069):655–66. 10.1016/S0140-6736(16)30668-7 . Dorsch NW. Therapeutic approaches to vasospasm in subarachnoid hemorrhage. Curr Opin Crit Care. 2002;8(2):115–20. Etminan N, Macdonald RL. Management of aneurysmal subarachnoid hemorrhage. Nat Rev Neurol. 2014;10(9):514–24. 10.1038/nrneurol.2014.148 . Westermaier T, Stetter C, Vince GH, et al. Prophylactic stellate ganglion block in patients with aneurysmal subarachnoid hemorrhage: impact on cerebral vasospasm. J Neurosurg Anesthesiol. 2013;25(2):132–8. 10.1097/ANA.0b013e31826df6df . Loewenfeld IE. Autonomic nervous system and pupillary function. In: Thompson HS, editor. The Pupil: Anatomy, Physiology, and Clinical Applications. Volume 1. Iowa State University; 1993. p. 181222. Jellish WS, Edelstein J. Cerebral blood flow and cerebral metabolism. In: Hemmings HC, Egan TD, editors. Pharmacology and Physiology for Anesthesia. Elsevier; 2013. pp. 221–34. Kim YD, Lee JW, Son BC. Effect of stellate ganglion block on cerebral vasospasm after subarachnoid hemorrhage. J Korean Neurosurg Soc. 2012;51(4):208–11. 10.3340/jkns.2012.51.4.208 . Park SH, Hwang JH, Park JH, et al. Cerebral hemodynamic improvement following stellate ganglion block in patients with cerebral vasospasm: a prospective observational study. Neurocrit Care. 2020;32(1):83–90. 10.1007/s12028-019-00747-3 . Koyama T, Inoue S, Morita K. Increase in cerebral tissue oxygenation after stellate ganglion block: a case report. JA Clin Rep. 2017;3(1):32. 10.1186/s40981-017-0109-6 . Choi YJ, Lee PB, Moon JY, et al. The role of stellate ganglion block in managing cerebral vasospasm: a systematic review. Pain Physician. 2021;24(4):E399–408. Treggiari MM, Manno EM, Lynch JJ, et al. Stellate ganglion block for cerebral vasospasm: Is there a role in multimodal management? J Neurosurg Anesthesiol. 2016;28(4):354–8. Rispoli M, Camporeale A, Cecchini S, et al. Stellate ganglion block in refractory cerebral vasospasm: a case series. Minerva Anestesiol. 2019;85(1):106–7. Narouze S, Vydyanathan A, Kapural L, et al. Ultrasound-guided stellate ganglion block: description of technique and efficacy of a new approach. Pain Pract. 2007;7(2):125–30. 10.1111/j.1533-2500.2007.00110.x . Wendel C, Oberhauser C, Schiff J, Henkes H, Ganslandt O. Stellate Ganglion Block and Intra-arterial Spasmolysis in Patients with Cerebral Vasospasm: A Retrospective Cohort Study. Neurocrit Care. 2023. Wu Y, Lin F, Bai Y, Liang F, Wang X, Wang B, et al. Early stellate ganglion block for improvement of postoperative cerebral blood flow velocity after aneurysmal subarachnoid hemorrhage: results of a pilot randomized controlled trial. J Neurosurg. 2023;1(aop):1–9. Davis J, Ozcan MS, Kamdar JK, Shoaib M. Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome. Regional Anesthesia & Pain Medicine; 2021. pp. rapm–2021. Goel V, Patwardhan AM, Ibrahim M, Howe CL, Schultz DM, Shankar H. Complications associated with stellate ganglion nerve block: a systematic review. Regional Anesthesia & Pain Medicine; 2019. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7309323","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501943133,"identity":"cb7e37b2-ee13-4d7f-a9fd-bcec7a7e07ec","order_by":0,"name":"Ahmed Abdelmabood","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Abdelmabood","suffix":""},{"id":501943134,"identity":"17a6eb78-d2bf-4241-92e7-11c4d994cc91","order_by":1,"name":"Ahmed Elsaied Abdelrahman","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Elsaied","lastName":"Abdelrahman","suffix":""},{"id":501943139,"identity":"7890eb82-a1b1-4ff8-b87d-06d044e61d60","order_by":2,"name":"Medhat Ibraheem","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Medhat","middleName":"","lastName":"Ibraheem","suffix":""},{"id":501943143,"identity":"7981d84c-9b82-414f-920c-f1111211b6b4","order_by":3,"name":"Khalid Mohamed Abdelal","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIie2PsUoDQRRFZxFis2L7Kv2FCYGJwrD5EJs3DMQmVjYWW0wIJI34A/oLgmmsJwxsFdx2YC12e4WtxCr4NqWwm6QTnFM9HvdwuYwFAn8RYJyV7IJzdmRsfCfpFU3tTgUZkBKRsh43itlfYSdzt312KqePs2WJKQyGx6up/ejlyfPCUUsqr1pL3rNbjhmIy3tlVk9xoV/XipRsfGPaHD8RgD2Q3CrjYii0oMNGxrUq534y/MYNKXlFCn/Tgo5OhVMLU3MQ3DctaBPhd7T0aQuoBxhwX9EWq1HQYbFjy1kxW9b1l+y/5NrVn5tkJPLrqqxT2T7/N2qbxH3jDaNDwoFAIPA/+AGnHW2nrGjRUAAAAABJRU5ErkJggg==","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Khalid","middleName":"Mohamed","lastName":"Abdelal","suffix":""},{"id":501943144,"identity":"c7703922-66e6-433e-80a8-c95040dfb405","order_by":4,"name":"ahmed ismaeel","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"ahmed","middleName":"","lastName":"ismaeel","suffix":""}],"badges":[],"createdAt":"2025-08-06 11:38:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7309323/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7309323/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89656733,"identity":"9f2e5f81-70ff-4dca-9d01-0c78972a8583","added_by":"auto","created_at":"2025-08-22 10:31:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":78592,"visible":true,"origin":"","legend":"\u003cp\u003eflow chart of patients participation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7309323/v1/ba3553f5fab2881018ea7104.png"},{"id":98874227,"identity":"c2b47a3b-7d96-4d8b-a119-5d47d69aeb5a","added_by":"auto","created_at":"2025-12-23 12:26:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1240344,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7309323/v1/604a54f3-9017-4887-8442-e8f7b8d6dd2e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Early cervical sympathectomy for management of cerebral vasospasm in traumatic head injuries a cross sectional prospective study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebral vasospasm is a major complication following traumatic head injury (SAH), contributing significantly to reduced cerebral perfusion and brain ischemia (DCI), neurological deterioration, and increased morbidity and mortality [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The current standard of care includes hemodynamic augmentation, calcium channel blockers (such as Nimodipine), and, in selected cases, endovascular interventions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite these interventions, treatment-refractory vasospasm continues to challenge clinicians and is associated with poor outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn recent years, \u003cb\u003estellate ganglion block (SGB)\u003c/b\u003e has gained attention as an adjuvant therapy in managing cerebral vasospasm. This sympathetic ganglion which is formed by the fusion of the inferior cervical and first thoracic sympathetic ganglia plays a key role in the regulation of cerebral vasculature [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Blocking this structure has been shown to produce regional vasodilation, increase cerebral blood flow, and reduce cerebrovascular resistance [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSeveral case reports and clinical studies have documented the effectiveness of SGB in improving cerebral perfusion in patients with refractory vasospasm, suggesting a promising therapeutic role [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Moreover, the procedure is relatively safe when performed under image guidance and may offer a minimally invasive alternative or supplement to traditional vasospasm therapies [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis article reviews the \u003cb\u003ephysiological rationale, technique, current clinical evidence, and potential role of SGB\u003c/b\u003e in the management of cerebral vasospasm following SAH, with a focus on its mechanisms of action and future research directions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study is a prospective cross-sectional study done in the Sohag University hospitals' intensive care unit during the period from 2021 to 2023\u003c/p\u003e\u003cp\u003e Following approval from the local Research Ethics Committee of the Faculty of Medicine at Sohag University, informed written consent was obtained from a first-degree relative of each patient for participation in the study. The research protocol was reviewed and aligned with the ethical principles outlined in the Declaration of Helsinki for medical research involving human subjects.\u003c/p\u003e\u003cp\u003eEthical committee approval number \u003cb\u003e( soh-Med-21-12-19)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eClinical trials registry number \u003cb\u003e(NCT05182619)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e30 adult patients underwent bilateral ultrasound-guided stellate ganglion block with 8 ml 0. 5% bupivacaine added to it 40 mg of betamethasone\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003cp\u003epatients older than 18 years with isolated traumatic brain injury and with evidence of cerebral vasospasm detected by transcranial Doppler\u0026thinsp;\u0026gt;\u0026thinsp;120cm/s in the middle cerebral artery.\u003c/p\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003eExclusion criteria\u003c/b\u003e:\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSevere hypotension (mean ABP less than 70 mmHg)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003esevere systemic illness including cardiac pulmonary failure or hepatic or renal impairment\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ehypersensitivity to one of the used drugs\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eimpaired blood coagulation\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003edisturbed neck anatomy by tumors or a huge thyroid gland\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDiabetic patients or patients with a history of vascular insufficiency\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eOn arrival to the emergency unit, all patients had first aid management according to their general condition, CT brain was done, GCS was assessed and recorded in the patient admission sheet, full monitoring by pulse oximetry, NIBP, ECG, was conducted and baseline readings were recorded.\u003c/p\u003e\u003cp\u003eCT brain data were recorded on arrival for pathology classification and staging.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eThe method of Stellate ganglion block:\u003c/h3\u003e\n\u003cp\u003ePatients were supine with their heads centered; a pillow was placed below the neck and shoulders if needed for optimal alignment. After performing aseptic skin preparation, a linear ultrasound probe (10 MHz) was placed on the neck to get a cross-sectional view of the anatomical structures. The transverse process of the C6 vertebra was identified first. The ultrasound probe was positioned at a 45-degree angle to the neck\u0026rsquo;s sagittal plane and adjusted as necessary to clearly visualize both the common carotid artery and the stellate ganglion.\u003c/p\u003e\u003cp\u003eAn echogenic blunt-tip ultrasound-guided 22-gauge needle was introduced laterally to the probe to avoid injury to the jugular vein and nearby neurovascular structures. The needle was advanced under continuous ultrasound guidance toward the stellate ganglion, located beneath the common carotid artery. Once the target was reached, a solution of 8 ml of 0.5% bupivacaine combined with 40 mg of betamethasone was injected. The needle was adjusted to ensure uniform distribution of the injectate.\u003c/p\u003e\u003cp\u003eSuccessful blockade was confirmed by the appearance of the manifestations of Horner\u0026rsquo;s syndrome on the injected side, including miosis, upper eye lid drop, enophthalmos, hyperemia at the conjunctiva, and facial flushing without sweating. Simultaneously, potential complications such as hematoma, pneumothorax, inadvertent epidural or subarachnoid block, hoarseness, esophageal trauma, and thyroid gland injury were monitored and documented.\u003c/p\u003e\n\u003ch3\u003ePatient follow-up and monitoring:\u003c/h3\u003e\n\u003cp\u003eContinuous monitoring of vital signs before and after initiation of the therapeutic procedure (pulse oximetry, ECG,, NIBP) and data was recorded continuously for the first thirty minutes from the start of the procedure, Special care was given to the early signs of phrenic nerve block including tachypnea respiratory distress, abdominal breathing as mechanical ventilation may be necessary.\u003c/p\u003e\u003cp\u003eTranscranial Doppler was done for all patients after admission to ICU and stabilization, middle cerebral artery was assessed through the temporal window and the basilar artery was assessed through the occipital window, Doppler scan was done by an efficient radiologist, trans-cranial Doppler was done before intervention, at first day after intervention (12hs) post intervention, second day, and then after one week.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eStatistical analysis was done using SPSS version 26 (IBM Corp., Chicago, IL, USA). Quantitative data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) and compared between the two groups using the unpaired Student\u0026rsquo;s t-test. Categorical data were expressed as counts and proportions, and comparisons were performed using the Chi-square test. Statistical significance was defined as a two-tailed p-value less than 0.05.\"\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSample size calculation:\u003c/h3\u003e\n\u003cp\u003eThe sample size was calculated for a one-group, pre-post comparison of cerebral blood flow velocity (CBFV) before and after Stellate Ganglion Block (SGB). Assuming a mean difference of 20 cm/s and a standard deviation of differences of 25 cm/s, with alpha\u0026thinsp;=\u0026thinsp;0.05 and power\u0026thinsp;=\u0026thinsp;80%, the required sample size was calculated to be 13 patients.\u003c/p\u003e\u003cp\u003eTo account for potential dropouts or incomplete measurements, we increased the sample size by 15%, resulting in a final total of 15 patients.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAs illustrated in flow chart we started with 40 pts, 5 patients refused participation, 5 pts didn\u0026rsquo;t meet inclusion criteria then 30 pts were enrolled.\u003c/p\u003e\u003cp\u003eFigure (1): flow chart of patients participation\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAs shown in Table\u0026nbsp;(1) we can find that the majority of cases that had cerebral vasospasm are patients with subarachnoid hemorrhage.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics and brain pathology of the studied group.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eBrain pathology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSAH\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25 (83.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003esubdural h\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (3.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003ebrain contusions\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (6.67%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eaxonal damage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (3.33%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThere was no difference in oxygen saturation or heart rate before and after intervention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(2): Oxygen saturation. Heart rate follow-up after intervention.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebaseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 ms after intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpo2 in%)percentage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e92.73\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e93.23\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.314\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHR (beat/minute)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e98.57\u0026thinsp;\u0026plusmn;\u0026thinsp;9.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e94.37\u0026thinsp;\u0026plusmn;\u0026thinsp;6.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.058\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are expressed in form of mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*: Significant as P value\u0026thinsp;\u0026le;\u0026thinsp;0.05. SpO2: Peripheral capillary oxygen saturation, HR: heart rate.\u003c/p\u003e\u003cp\u003eMBP was insignificantly different in comparison to baseline at 15 m, 30 m, and 60 ms.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(3): Follow-up of MBP of the studied group.(mmHg)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ebaseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.62\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15 m\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30m\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.23\u0026thinsp;\u0026plusmn;\u0026thinsp;9.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e60m\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP1 0.5448\u003c/p\u003e\u003cp\u003eP2 \u0026nbsp;0.4551\u003c/p\u003e\u003cp\u003eP3 \u0026nbsp;0.6224\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e. MBP: Mean blood pressure, p-value is insignificant as \u0026gt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMiddle cerebral artery measurements showed significantly different reduction on the 1st day, 2nd day, and one week in comparison to the baseline (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(4): Middle cerebral Doppler measurements follow-up of the studied group.(cm/second)\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e155.33\u0026thinsp;\u0026plusmn;\u0026thinsp;9.55\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e134.67\u0026thinsp;\u0026plusmn;\u0026thinsp;11.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e130.67\u0026thinsp;\u0026plusmn;\u0026thinsp;12.58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e133.97\u0026thinsp;\u0026plusmn;\u0026thinsp;14.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eP1\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003cp\u003eP2\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003cp\u003eP3\u0026thinsp;\u0026lt;\u0026thinsp;\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*: Significant as P value\u0026thinsp;\u0026le;\u0026thinsp;0.05. P1: P value between baseline and 1st day, P2: P value between baseline and 2nd day, P3: P value between baseline and one week.\u003c/p\u003e\u003cp\u003eBasilar artery measurements showed a significantly different reduction on the 1st day, 2nd day, and one week in comparison to the baseline (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(5): Basilar artery measurements of the studied groups in (cm/second).\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroup S\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e84.33\u0026thinsp;\u0026plusmn;\u0026thinsp;5.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81.33\u0026thinsp;\u0026plusmn;\u0026thinsp;4.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP1\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003cp\u003eP2\u0026thinsp;\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003cp\u003eP3\u0026thinsp;\u0026lt;\u0026thinsp;\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*: Significant as P value\u0026thinsp;\u0026le;\u0026thinsp;0.05. P1: P value between baseline and 1st day, P2: P value between baseline and 2nd day, P3: P value between baseline and one week.\u003c/p\u003e\u003cp\u003eThere was a clinical improvement in GCS after one week in comparison to the baseline (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(6): GCS at baseline and after one month of the studied group.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabe\" border=\"1\"\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11.47\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAfter one week\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c3\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRT hemiplegia patients with clinical improvement after one week was (83%) while LT hemiplegia patients with clinical improvement after one week was (4%)\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;(7): Neurological evaluation after one week of the studied group.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabf\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBaseline number\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eImproved pts\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003epercentage\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRt motor deficit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLt motor deficit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs regards patients' diagnosis before scanning for cerebral vasospasm, we can find that the majority of cases had subarachnoid hemorrhage complicated by 2ry cerebral vasospasm (83.3%) of patients\u003c/p\u003e\u003cp\u003eWe can find that vital signs including heart rate, mean arterial blood pressure, and oxygen saturation were not affected by the intervention.\u003c/p\u003e\u003cp\u003eAs regards transcranial Doppler follow-up at the middle cerebral artery Doppler, there was a significant reduction in cerebral blood velocity meaning a reduction in cerebral vasospasm after the intervention \u003cb\u003eat 1st day, 2nd day, and one week in comparison to baseline.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSimilar results could be found in the comparison of measurements at the basilar artery compared to baseline, there was a significant reduction \u003cb\u003eon the 1st day, 2nd day, and one week in comparison to baseline.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThese findings align with those reported by Wu et al. (2023) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], who conducted a study utilizing transcranial Doppler (TCD) ultrasonography to evaluate changes in cerebral blood flow velocity (CBFV) on both the ipsilateral and contralateral sides of the brain within the first 24 hours following stellate ganglion block (SGB) administration in patients with cerebral vasospasm (CV) unresponsive to maximal standard treatment. A total of 76 SGB procedures were performed, with some patients receiving up to four blocks., A total of 76 stellate ganglion blocks (SGBs) were performed in the study. Two hours following the initial SGB, cerebral blood flow velocity (CBFV) showed a significant reduction in 80.5% of patients, decreasing from a mean of 160.3\u0026thinsp;\u0026plusmn;\u0026thinsp;28.2 cm/sec to 127.5\u0026thinsp;\u0026plusmn;\u0026thinsp;34.3 cm/sec (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, after 24 hours, 63.4% of patients exhibited a further decline in CBFV, reaching 137.2\u0026thinsp;\u0026plusmn;\u0026thinsp;38.2 cm/sec (p\u0026thinsp;=\u0026thinsp;0.007), indicating a statistically significant change.. A comparable effect was observed with subsequent stellate ganglion blocks. Notably, there was no reduction in blood flow within the contralateral middle cerebral artery (MCA) following SGB. The findings revealed a significant decrease in ipsilateral CBFV within the MCA\u0026mdash;approximately 20.5%\u0026mdash;after the procedure, with this effect persisting for more than 24 hours in nearly two-thirds of patients. Importantly, no major complications were reported as a result of the SGB.\u003c/p\u003e\u003cp\u003eAlso, Christopher \u003cb\u003eWendel et al.(2019)\u003c/b\u003e [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] examined the impact of stellate ganglion block on cerebral vasospasm following subarachnoid hemorrhage. They performed SGB on the side where the highest CBFV had been recorded with 8\u0026ndash;10 ml of ropivacaine 0.2%. The patient\u0026rsquo;s CBFV was remeasured after 2 and 24 hours. Within two hours of the initial stellate ganglion block, a reduction in cerebral blood flow velocity (CBFV) was observed in 80.5% of patients, with the mean value decreasing from 160.3\u0026thinsp;\u0026plusmn;\u0026thinsp;28.2 cm/sec to 127.5\u0026thinsp;\u0026plusmn;\u0026thinsp;34.3 cm/sec (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). After 24 hours, 63.4% of patients continued to show a decline in CBFV, reaching an average of 137.2\u0026thinsp;\u0026plusmn;\u0026thinsp;38.2 cm/sec (p\u0026thinsp;=\u0026thinsp;0.007). \u003cb\u003eRegarding the comparison of the patient prognosis and Glasgow coma scale GCS improvement in both groups there was significant improvement in GCS after the intervention, As regards comparison at the level of clinical improvement of motor deficit, (83.3%) of right-sided hemiplegia clinically improved wile (40%) of lt sided hemiplegia patients clinically improved\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis finding is consistent with the results reported by Davis et al \u003cb\u003e(2021)\u003c/b\u003e \u003csup\u003e(17)\u003c/sup\u003e A stellate ganglion block (SGB) was administered to a patient diagnosed with severe reversible cerebral vasoconstriction syndrome, with transcranial Doppler used to monitor cerebral vasospasm. Improvement in cerebral blood flow was associated with a progressive resolution of acute neurological symptoms, including motor deficits, and the patient reported the absence of headache the next day.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBilateral stellate ganglion block was done ultrasound-guided with no documented complications in 30 patients.\u003c/b\u003e\u003c/p\u003e\u003cp\u003eContrary to our results, \u003cb\u003eGoel et al., (2019)\u003c/b\u003e \u003csup\u003e(18)\u003c/sup\u003e reported complications of SGB that are rare but can be life-threatening. The reported incidence of severe complications was 1.7 per 1,000 stellate ganglion blocks, based on a total of 45,000 procedures, with most adverse events being neurological, such as convulsions, Of these cases, six were attributed to high subarachnoid block, three to high epidural blockade, nine to pneumothorax, and two were due to allergic reactions. The detection of these complications was likely facilitated by the large sample size, in contrast to our study, which involved a relatively smaller cohort.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eEarly stellate ganglion block is an efficient method for the reduction of cerebral vasospasm that can improve outcome, reduce morbidity, and provide clinical improvement in neurological deficit resulting from post-traumatic cerebral vasospasm.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis report complies with regional and institutional ethical guidelines and with declaration of Helsinki. A written informed consent was obtained from the first degree relative of all our cases \u0026nbsp;before participation in the research\u003c/p\u003e\n\u003cp\u003eEthical committee approval number \u003cstrong\u003e( soh-Med-21-12-19)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical trials registry number \u003cstrong\u003e(NCT05182619), registration date 10/12/2021\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubmission declaration and verification:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors of this paper have approved the final version to be submitted; The contents of this manuscript have not been copyrighted or published previously nor under consideration for publication elsewhere; The contents of this manuscript will not be copyrighted, submitted, or published elsewhere, while acceptance by the Journal is under consideration; There are no directly related manuscripts or abstracts, published or unpublished, by any authors of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent of publication\u003c/strong\u003e: Not Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAny data or materials related to the case are readily available for revision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003enone \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003enone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eConnolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. 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Neurocrit Care. 2023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu Y, Lin F, Bai Y, Liang F, Wang X, Wang B, et al. Early stellate ganglion block for improvement of postoperative cerebral blood flow velocity after aneurysmal subarachnoid hemorrhage: results of a pilot randomized controlled trial. J Neurosurg. 2023;1(aop):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavis J, Ozcan MS, Kamdar JK, Shoaib M. Stellate ganglion block used to treat reversible cerebral vasoconstriction syndrome. Regional Anesthesia \u0026amp; Pain Medicine; 2021. pp. rapm\u0026ndash;2021.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGoel V, Patwardhan AM, Ibrahim M, Howe CL, Schultz DM, Shankar H. Complications associated with stellate ganglion nerve block: a systematic review. Regional Anesthesia \u0026amp; Pain Medicine; 2019.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"stellate block, cerebral blood flow, neurological improvement","lastPublishedDoi":"10.21203/rs.3.rs-7309323/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7309323/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction\u003c/b\u003e: Head trauma is a leading cause for both death and disability among patients (3),. It can result in a wide range of pathological conditions (7), with cerebral vasospasm being a frequently encountered complication (1,8), Several treatment approaches are employed to manage cerebral vasospasm (6), cervical symoathectomy in the form of stellate ganglion block is one of these methods (11)\u003c/p\u003e\u003cp\u003e\u003cb\u003eAim of the study\u003c/b\u003e: assessment of the effect of cervical sympathectomy on the reduction of cerebral vasospasm primarily and secondarily the impact of this reduction on patient follow-up and prognosis.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e: 30 adult patients with isolated head trauma injury had a bilateral ultrasound-guided stellate block with 8 ml 0.5% bupivacaine and 40 mg of betamethasone.\u003c/p\u003e\u003cp\u003ePatient follow-up included hemodynamics, Transcranial-Doppler for middle cerebral artery, basilar artery, GCS, and improvement and motor deficit after one week of follow-up.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e: we found that cerebral vasospasm improved, MCA measurements improved in comparison to baseline at 1\u003csup\u003eST\u003c/sup\u003e day, 2\u003csup\u003eND\u003c/sup\u003e day, and after one week, (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). GCS was better in comparison to baseline after one week (P value\u0026thinsp;\u0026lt;\u0026thinsp;0.001). MBP was unaffected in comparison to the baseline, after 15, 30, and 60 minutes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e: Early cervical sympathectomy is an efficient method for the reduction of cerebrovascular spasm after traumatic brain injury.\u003c/p\u003e\u003cp\u003eCkinical trials registry number \u003cb\u003eNCT05182619, registry date 10/12/2021\u003c/b\u003e\u003c/p\u003e","manuscriptTitle":"Early cervical sympathectomy for management of cerebral vasospasm in traumatic head injuries a cross sectional prospective study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 10:31:18","doi":"10.21203/rs.3.rs-7309323/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"312c0e32-7506-479f-b8bc-11a50af98864","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-23T12:26:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-22 10:31:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7309323","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7309323","identity":"rs-7309323","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}