What Is Vasospasm? 

Defining vasospasm 

A vasospasm is defined as a tightening or constriction of an artery over a protracted period of time.¹ Due to this constriction, the width of the artery through which blood can pass is greatly reduced. As such, the volume of blood reaching the area supplied by this artery is also decreased, resulting in less oxygen reaching its desired destination.² Vasospasms have numerous causes and can manifest as various symptoms depending on the artery impacted. Therefore, we will seek to explore and address all relevant topics related to vasospasm. 

Where do vasospasms most commonly occur? 

Vasospasms can occur in various arteries throughout the body, making their detection challenging due to the array of symptoms they can produce. Analogous to diagnosing car issues, where exhaust problems might alter the engine's sound or smoke emissions, vasospasm-related symptoms depend on the affected area. The most critical sites for vasospasms are the coronary arteries, which supply blood to the heart, potentially leading to heart attacks. Cerebral arteries, supplying the brain, are also susceptible, affecting speech, motor functions (the ability to move aspects of the body), and vision. Notably, cerebral artery vasospasms typically occur following a subarachnoid hemorrhage, a topic that will be explored in greater depth later in the article. 

Causes of vasospasm 

Vasospasm is caused by prolonged tightening and constriction of an artery.¹ Artery walls are made of three layers, each with its function and purpose. Most important to the context of vasospasm is the middle layer of the artery, which is known as the tunica media. This layer is made of muscular tissue and acts just like any other muscle throughout the body. For example, when stimulated by the nervous system, this layer contracts and tightens the artery, reducing the space which blood can flow through. This process is known as vasoconstriction.2 As such, when the tunica media fails to relax and thus maintains constriction of the artery for longer than normal, this becomes what is known as vasospasm. Research has shown there to be numerous causes and predispositions for this vascular dysfunction depending on the site of the body at which the vasospasm occurs. Below, you will find a list of these.

Coronary artery vasospasms and their causes  

Coronary vasospasms, characterized by the rapid constriction of heart-supplying blood vessels,³ are a potentially fatal form of vasospasm. While the precise causes remain incompletely understood, various factors are associated with their occurrence:

1. Atherosclerosis: Often secondary to atherosclerosis, the buildup of arterial plaques can damage artery walls, making them more sensitive to neurotransmitters like serotonin. Serotonin can trigger artery constriction⁴, leading to vasospasms, which pose a risk of plaque rupture and thrombus (blood clot) formation, potentially causing a heart attack.
2. Chemotherapy: Some cancer patients, particularly those receiving chemotherapy treatment for conditions like colorectal cancer, have reported vasospasms.⁵
3. Illicit drug use: Cocaine is known to induce coronary vasospasms, likely due to its stimulant effects that affect heart rate and blood pressure.⁶ Amphetamine overuse can similarly trigger vasospasms.⁷ Cannabis smoking can disrupt artery wall function, increasing susceptibility to vasoconstriction and vasospasms.⁸
4. Inflammation: Inflammatory processes are also thought to contribute to vasospasms.

Coronary vasospasms are a critical medical concern due to their potential for serious complications, including heart attacks.

Cerebral vasospasms and their causes

Cerebral vasospasms, defined as prolonged constrictions of brain-supplying blood vessels,⁹ are typically secondary to a brain bleed. A subarachnoid haemorrhage is a type of brain bleed where blood accumulates around the brain, elevating the pressure on the brain. This type of bleed is a medical emergency and often leads to vasospasms within approximately three days.¹⁰ Another common cause of brain bleeds is ruptured cerebral aneurysms, where blood vessel walls in the brain balloon due to weakness in its structure.  This type of brain bleed can also induce vasospasms. Exposure to vasoactive substances (compounds that dilate a blood vessel) following a bleed, including serotonin, can similarly trigger cerebral vasospasms,¹⁰ parallel to the biochemical mechanisms seen in coronary artery vasospasms. These vasospasms occur as a response to events preceding them, typically involving irritation and inflammation due to the pressure of blood exerted on the outer layers of arterial walls following a brain bleed.

Vasospasms in the extremities and their causes 

Vasospasms seen in patients' fingers and toes are commonly seen in many conditions. The most notorious and often most familiar to patients is a condition known as Raynaud’s Syndrome.  This condition specifically relates to a reduced flow of blood to patients’ fingers due to vasospasms of the arteries supplying that area. In rare cases, this condition can also impact blood flow to patients’ toes, ears, nose, nipples, or knees.¹¹ The most common cause of this phenomenon is thought to be due to sudden exposure to colder temperatures. There are also other conditions that can give rise to vasospasms in patients’ toes and fingers, such as: 

• Lupus
• Scleroderma 
• Atherosclerosis  
• Sjogren Syndrome 
• Rheumatoid Arthritis. 

Symptoms of vasospasm 

  As you have most likely gathered, the symptoms of vasospasm are highly dependent on the area of the body in which they occur. As above, we will endeavour to categorize the symptoms as either coronary-, cerebral- or extremity-related. 

Symptoms of coronary artery vasospasm

Coronary artery spasms, which can sometimes be asymptomatic (‘silent’),¹² are often associated with chest pain when symptoms occur. This chest pain is commonly described as tightness, crushing, squeezing (often in a 'band-like' pattern), constricting, or pressure (similar to someone sitting on the chest). These symptoms typically manifest during rest, particularly after midnight or early morning,³ and patients may wake up with them. The frequency of vasospasms varies among individuals, occurring as infrequently as once a year or multiple times in a day. Chest pain typically lasts for 5-30 minutes,¹² and medical attention should be sought if it persists beyond this timeframe.

Symptoms of cerebral vasospasm¹ 

Whilst the vast majority of cerebral vasospasms are attributed to direct bleeds in the brain, there are several symptoms which can indicate the presence of a cerebral vasospasm. General symptoms indicative of cerebral vasospasm include: 

• Neck stiffness 
• A fever 
• Difficulty with speech 
• Confusion 
• Weakness on one side of the body 

In some cases, patients may also experience stroke-like symptoms, which can present in several different ways: 

• Numbness, weakness or paraesthesia (tingling) impacting either the face, arms or legs that most often occurs on one side of the body
• Visual disturbance in one or both eyes
• Dizziness, nausea or difficulty coordinating movements 
• Difficulty walking 
• A severe headache without a recognisable cause 

Symptoms of vasospasm in the extremities¹³ 

Most commonly seen in Raynaud’s Syndrome, the common triggers of Raynaud’s include: 

• Sudden exposure to cold temperatures 
• Anxiety or high levels of stress

If Raynaud’s syndrome is present, patients often complain of a change of colour to their fingers or toes. In Caucasian patients, this typically presents as a change from red to pale white. In those patients of Black-African origin, the skin often turns paler. Along with  this colour change, patients also commonly reported the following symptoms: 

• Pain 
• Changes in sensation 
• Numbness 
• Pins and needles 

How is vasospasm diagnosed? 

Before conducting a physical examination, obtaining a medical history is often instrumental in identifying any key aspects of a patient’s health that may point to a diagnosis of vasospasm. A physical examination can then be used to identify and confirm symptoms of vasospasm. Further diagnostic processes are also essential to confirm the diagnosis of vasospasm. These include: 

• ECG (electrocardiogram): This method is used to detect any abnormalities in the heart and can give clues as to the location of the coronary artery vasospasm 
• CT Angiography: Clinicians will inject a dye into the coronary arteries before performing a scan using a CT scanner. This allows them to identify the area of vasospasm
• MRI: This may be used to visualize the exact area of vasospasm in the body
• Doppler Ultrasound: This is a scan used to detect the flow of blood through an artery and can detect areas of reduced blood flow due to vasoconstriction 
• Blood Tests: These may be done to look for more serious underlying conditions which could be causing Raynaud’s Syndrome

Treatment and management of vasospasm 

There are numerous treatments and preventions available for vasospasm. To reduce the chance of experiencing vasospasm, it is recommended that the following lifestyle changes are implemented: 

• Adhering to smoking cessation plans
• Developing methods to cope with stress 
• Maintaining a warm environment whilst at home and ensuring toes and fingers are adequately covered and insulated when exposed to colder temperatures

Treating coronary artery vasospasm

The treatment of coronary artery vasospasm is largely through medication and includes the following: 

• Calcium-channel blockers: These are the first-line treatment of coronary artery vasospasm. These reduce the amount of calcium absorbed by the muscle layer of the artery, thus relaxing the vessel¹⁴
• Statins: These help lower cholesterol levels and improve the health of blood vessels 
• ACE-inhibitors: These help to reduce blood pressure and also help improve vascular health

Patients are also advised to adopt a series of lifestyle measures to reduce the risk of suffering from vasospasm: 

• Weight loss 
• Smoking cessation 
• Refraining from engaging with illicit drugs such as cocaine, amphetamines and cannabis 

Treating cerebral artery vasospasm 

The treatments for cerebral artery vasospasm are largely similar to the treatment for coronary artery vasospasm and include: 

• Giving a vasodilator (drugs that open your blood vessels) such as nimodipine or verapamil (calcium-channel blockers). These are usually given intravenously, i.e., through the veins.
• Increasing fluid intake 
• Increasing blood pressure 

Treating vasospasm of the extremities 

Similar to the other types of vasospasm, vasospasm of the extremities also require the use of calcium-channel blockers to reduce the severity of symptoms. This is most commonly done by administering nifedipine. There are also several additional measures patients should adopt to reduce the impact of vasospasm in their extremities: 

• Ensuring fingers and toes are sufficiently covered in cold temperatures through the use of mittens, gloves and additional socks
• Avoiding the use of tobacco products
• Reducing levels of stress 

Summary 

Vasospasm, characterized by prolonged blood vessel constriction, primarily affects the brain, heart, and extremities like fingers and toes. Cerebral vasospasms mimic stroke-like symptoms, while coronary artery vasospasms resemble heart attack symptoms. Extremity vasospasms result in colour and sensation changes in toes or fingers. Diagnosing the location of vasospasm requires carrying out various tests and scans that can visualise the affected arteries. Treatment for all types of vasospasm typically involves medication, with calcium-channel blockers as the primary choice. Preventative measures include lifestyle changes like quitting smoking and better stress management. Prompt diagnosis and treatment are essential for managing these vascular events effectively.