An Inflammatory Soup

Immediately following SAH, complex series of biochemical cascades associated with coagulation, complement activation, inflammation, and processes of phagocytosis and repair, such as the release and synthesis of growth factors, are activated. These systems are in place to promote wound healing. However, given the large amount of blood that remains trapped in the sub-arachnoid space and the unusual vulnerability of the cerebral arteries, these triggered responses may cause more harm than benefit.

Additionally, the gradual breakdown of erythrocytes results in high concentrations of free hemoglobin. It is uncertain how hemoglobin causes vasospasm. Proposed mechanisms include direct action on VSMCs, scavenging of NO, and increased production of endothelin, free radicals, lipid peroxidases, and eicosanoids (17). However, pure hemoglobin does not readily increase intracellular calcium levels and is not particularly toxic to VSMCs, suggesting that the indirect effects of hemoglobin are probably more important (38).

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