Rescue Therapy for Refractory Vasospasm after Subarachnoid Hemorrhage

Abstract

Vasospasm and delayed cerebral ischemia remain to be the common causes of increased morbidity and mortality after aneurysmal subarachnoid hemorrhage. The majority of clinical vasospasm responds to hemodynamic augmentation and direct vascular intervention; however, a percentage of patients continue to have symptoms and neurological decline. Despite suboptimal evidence, clinicians have several options in treating refractory vasospasm in aneurysmal subarachnoid hemorrhage (aSAH), including cerebral blood flow enhancement, intra-arterial manipulations, and intra-arterial and intrathecal infusions. This review addresses standard treatments as well as emerging novel therapies aimed at improving cerebral perfusion and ameliorating the neurologic deterioration associated with vasospasm and delayed cerebral ischemia.

Prevention and treatment of cerebral vasospasm after aneurysmalsubarachnoid hemorrhage

“…As established vasospasm prophylaxis, CCB were investigated for their potential role in treatment 19 . Nimodipine, an L-type CCB, is currently the only pharmacologic agent showing an improvement in neurological outcomes when used for a period of 21 days, every 4 h after aneurysmal rupture, suggested by the current guidelines of the American Stroke Association 14,16 .Intravenous nicardipinedidn't show effect on outcomes after three months of use and verapamil is not selective to cerebral vasculature and its use requires more research 5,14 .…”

“…17 Later publications showed that PTA reverses angiographic spasm of large proximal CVS, augments CBF, and may reverse neurological deficits 5,13 . Angioplasty with intraarterial (IA) administration of papaverine may show better efficacy when distal vessels are affected with CVS 9 .Some investigators have suggested that IA papaverine has influence on paradoxical vasospasm, increased intracranial pressure and has neurotoxic effects, which limited its clinical utility 9,19,22 . Several case series have shown better safety results of other IA vasodilators, including: verapamil, nicardipine, nimodipine, and milrinone, than papaverine, but that was not supported by adequate trials 5,17 .Several retrospective studies with propose neurological progress after one dose of IA verapamil…”

“….Clinical studies with antiplatelet agents and inhibitors of thrombus formation showed contrasting outcomes: one study showed reduced risk of cerebral infarction in patients using aspirin and another study showed increased hemorrhagic volume in patients habitually using cyclooxygenase inhibitors 16,19 . Experimental models showed improvement of neurological performanceafter limitation of neuronal inflammation 16 .…”

“…. There are evidences that indicate reduction of angiographic evidence of spasm after treatment with IA nicardipine bolus 19,21 . IA Dantrolene might be valuable in serious cases and was also used intravenously for treatment of refractory vasospasm 19,22 .A small case series of patients who were treated with continuous IAnimodipine for 1-5 days had improvement in angiographic vasospasm, and 13 of them gave the impression of good respond to treatment 19 .…”

“…Intraluminal balloon angioplasty has best treatment reportsfor refractory vasospasm due to the enhancement in vessel diameter and clinical improvement after treatment 19,22 .This intervention is often used in patients that don't show improvementafterhyperdynamic therapy 9,21 . It is performed by a catheter that introduces a balloon, which is inflated inside the lumen of the affected vessel 19 .In general, balloon angioplasty can be used for accessible lesions and accompanies infusion of vasodilators such as CCB and phosphodiesterase inhibitor (milrinone) for more distal vessels 9 .…”