Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage

Abstract

ObjectiveDelayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.MaterialsData from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.ResultsThe final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.ConclusionsA preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.Classification of evidenceThis study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.

Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older

“…Insights into the causes of death should be prospectively assessed to improve care and clinical outcomes, especially for elderly patients with aSAH [38]. Fourth, detailed information on the frequent and early use of endovascular treatment for cerebral vasospasm was not analyzed in this study [44]. A further study is required to determine the effect of unmeasured confounders.…”

In the wall lies the truth: a systematic review of diagnostic markers in intracranial aneurysms

“…Except for syndromal and infectious cases, saccular intracranial aneurysms (IA) are usually slowly growing vascular lesions. While IA may remain mostly asymptomatic over years, their sudden rupture leads to heavy burden of subarachnoid hemorrhage with poor outcome despite maximal treatment (16).…”

How do I manage cerebral vasospasm and delayed cerebral ischemia?

“…Recent observational studies indicate that early and repeated endovascular treatment might be associated with better outcome. 30 Several drugs can be used, including calcium channel blockers (nimodipine, nicardipine or verapamil) and phosphodiesterase inhibitors (milrinone, or papaverine), but none has been investigated in a controlled trial. We use nimodipine.…”