The Impact of Endovascular Rescue Therapy on the Clinical and Radiological Outcome After Aneurysmal Subarachnoid Hemorrhage: A Safe and Effective Treatment Option for Hemodynamically Relevant Vasospasm?

Abstract

ObjectiveCerebral vasospasm (CVS) represents one of the multiple contributors to delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH). Especially the management of CVS, refractory to medical treatment, is a challenging task during the acute phase after aSAH. Endovascular rescue therapies (ERT), such as medical and mechanical dilation, are possible treatment options on an individual basis. However, data about the influence on the patients' functional outcomes are limited. This study aims to assess the impact of ERT on the long-term functional outcome in aSAH-patients with refractory CVS.MethodsWe performed a retrospective analysis of aSAH patients treated between 2012 and 2018. CVS was considered refractory, if it persisted despite oral/intravenous nimodipine application and induced hypertension. The decision to perform ETR was made on an individual basis, according to the detection of “tissue at risk” on computed tomography perfusion (CTP) scans and CVS on computed tomography angiography (CTA) or digital subtraction angiography (DSA). The functional outcome was assessed according to the modified Rankin scale (mRS) 3 months after the ictus, whereas an mRS ≤ 2 was considered as a good outcome.ResultsA total of 268 patients were included. Out of these, 205 patients (76.5%) were treated without ERT (group 1) and 63 patients (23.5%) with ERT (group 2). In 20 patients (31.8%) balloon dilatation was performed, in 23 patients (36.5%) intra-arterial nimodipine injection alone, and in 20 patients (31.8%) both procedures were combined. Considering only the patient group with DCI, the patients who were treated with ERT had a significantly better outcome compared to the patients without ERT (Mann–Whitney test, p = 0.02).ConclusionEndovascular rescue therapies resulted in a significantly better functional outcome in patients with DCI compared to the patient group treated without ETR. CTP and CTA-based identification of “tissue at risk” might be a reliable tool for patient selection for performing ERT.

Serum concentration–guided intravenous magnesium sulfate administration for neuroprotection in patients with aneurysmal subarachnoid hemorrhage: a retrospective evaluation of a 12-year single-center experience

“…To date, there are no larger randomized controlled trials investigating the impacts of endovascular treatment for vasospasm. However, several recent retrospective studies confirmed that early endovascular vasospasm treatment improves functional outcomes and may be effective against the development of DCI [ 40 – 42 ].…”

Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018–2021: an overview of the current care situation

“…Hingegen mangelt es an prospektiven randomisierten Studienergebnissen zur Wirksamkeit von endovaskulären Spasmustherapien (EST); diese werden jedoch u. a. in Leitlinien der amerikanischen Fachgesellschaften zur additiven Behandlung von ZVS explizit erwähnt [5]. Unzweifelhaft werden angiografische Interventionen mit lokaler Applikation von gefäßerweiternden Medikamenten und auch die Ballonangioplastie (BA) in sehr vielen Institutionen auch in Mitteleuropa und speziell Deutschland durchgeführt [3,7,8].…”

“…In contrast, there is a lack of prospective randomized trial results on the efficacy of endovascular vasospasm treatments (EVT); however, these are explicitly mentioned in, among others, guidelines of the American professional societies on additive treatment of CVS [5]. There is no doubt that angiographic interventions with topical application of vascular vasodilators as well as balloon angioplasty (BA) are performed in a very large number of institutions, including in Central Europe and especially Germany [3,7,8].…”

Neuroradiological diagnosis and therapy of cerebral vasospasm after subarachnoid hemorrhage

“…However, a clear recommendation is lacking here as for endovascular spasm therapy (EST). This is also due to the fact that to date there is no evidence of a positive effect on clinical outcome even though there are indications of an additional benefit of EST based on numerous at times complicated studies including metaanalyses [17][18][19][20][21]. Thus, there is also currently a lack of consensusbased guidelines regarding EST even though they are broadly implemented and include the intraarterial administration of medication (also in the form of continuous therapy with microcatheters) and mechanical vascular dilation (balloon angioplasty [BA], dilation by means of other instruments, e. g. stent retrievers, stenting).…”

“…Jedoch fehlt hierfür ebenso eine klare Empfehlung wie für endovaskuläre Spasmustherapien (EST). Auch dies ist dem Umstand geschuldet, dass bislang keine Evidenzen für einen positiven Einfluss auf den klinischen Ausgang vorliegen, obgleich sich Hinweise auf einen zusätzlichen Nutzen von EST aus zahlreichen, teils aufwändig konzipierten Studien unter Berücksichtigung auch von Metaanalysen ergeben [17][18][19][20][21]. So mangelt es also auch aktuell an konsentierten Leitlinien für EST, welche jedoch unzweifelhaft ubiquitär durchgeführt werden und dabei intraarterielle Medikamentengaben (auch als Dauertherapien mit Mikrokathetern) und mechanische Gefäßerweiterungen (Ballonangioplastie [BA], Dilatationen durch andere Instrumente wie z.…”