Original articleInstitution of sustained endovascular treatment prior to clinical deterioration in patients with severe angiographic vasospasm: A retrospective observational study of clinico-radiological outcomes
Introduction
Cerebral infarction is strongly associated with poor outcome following SAH [1], [2]. Aetiologies include the acute injury [3], aneurysm treatment, or delayed ischaemia [4]. Proposed mechanisms for delayed ischaemia, either alone or in combination [4], [5], include microthrombosis, spreading depolarisation with cortical ischaemia and angiographic vasospasm (aVSP). The contribution of the latter is controversial [5], [6], [7], largely stemming from the finding that endothelin-receptor antagonists reduce the rate of moderate-severe aVSP but not the rate of poor outcome [8], [9]. However, there is a strong correlation between the severity of aVSP and infarct incidence [10]. The majority of delayed infarcts occur in association with aVSP [10], [11], [12], mostly with severe aVSP [10], [13], [14], which results in the most significant perfusion deficits [14], [15], [16], [17]. Severe aVSP is associated with poor cognition, worse patient-relevant outcomes, and greater inpatient healthcare resource use [18].
Two endovascular approaches have been employed to treat vasospasm; prophylactic TBA before vasospasm onset [19] or, use of TBA and/or IA vasodilators as a rescue procedure in patients who deteriorate despite medical therapy. The former approach may result in unnecessary treatments. The latter relies on early detection of clinical deterioration. However, these patients are often poor grade, comatose or sedated and difficult to assess. They may suffer silent infarction that itself has a negative impact on outcome [20], [21], [22]. An alternative approach is to screen for vasospasm with the intention of treating it while it is minimally symptomatic. We routinely undertake a program of angiographic surveillance at days 5–7 post-ictus, at or just before the time that most patients become symptomatic [23], [24] with subsequent endovascular treatment (multiple procedures where necessary) based on symptomology and radiographic features. We hypothesised that using this approach and comparing to benchmarks in the literature, rates of infarction and clinical outcomes were favourable.
Section snippets
Methods
This was a dual-centre retrospective observational study of patients with severe aVSP following aneurysmal SAH treated between November 2009 and December 2013. The study was approved by the regional ethics committee. Patients included were defined as having severe aVSP on the basis of > 66% arterial narrowing [10] on initial screening or subsequent DSAs. Statistical analysis was performed using Openstat software, 2013. Univariate analysis of non-parametric variables and their relationship to
Results
Fifty-seven patients were included: 18 males (31.6%) and 39 females (68.4%) of mean age 50.4 ± 3.0 years. Clinico-radiological features at presentation are shown in Table 1. Twenty-two patients (38.6%) were clipped and 35 patients (61.4%) were coiled. The aneurysm responsible for the haemorrhage was anterior circulation in 47 (82.5%) [ACA 24, ICA 14 and MCA 9] and posterior circulation in 10 (17.5%). Seven aneurysms (12.3%) were large (≥ 10 mm) and one was giant. Eleven patients (19.3%) presented >
Discussion
Two established philosophies exist for endovascular vasospasm management: prophylactic TBA or rescue therapy. We use an intermediate paradigm, identifying aVSP and commencing treatment prior to neurological deterioration or whilst the patient is minimally symptomatic. Rates of cerebral infarction and clinical outcome were assessed.
Rates of infarction associated with severe aVSP range from 46–81% (see Table 6) [10], [13], [14]. In contrast, when patients presented within 72 hours and were treated
Conclusion
This study suggests that an intensive endovascular approach of TBA and multiple IA verapamil infusions can result in low rates of vasospasm-associated infarction and encouraging rates of favourable outcome when compared to literature benchmarks if treatment is instituted early when the patient is minimally symptomatic. Delayed presentation, however, predicts infarction and large infarct and poor initial grade significantly influence functional outcome. Further investigation is needed to fully
Contributions
All authors contributed to the manuscript and study.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
Ethics approval: Northern Sydney and Central Coast Ethics Committee.
Acknowledgements
Professor R.L. Macdonald (university of Toronto) and Actelion (San Francisco, California, USA) for providing clinical outcome data for patients with severe angiographic vasospasm in the CONSCIOUS-1 trial.
References (53)
- et al.
Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm
Br J Anaesth
(2012) - et al.
Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2)
Lancet Neurol
(2011) - et al.
Timing of symptomatic vasospasm in aneurysmal subarachnoid haemorrhage: the effect of treatment modality and clinical implications
J Stroke Crebrovasc Dis
(2010) - et al.
Endovascular management of cerebral vasospasm following anaerysm rupture: outcomes and predictors in 116 patients
Clin Neurol Neurosurg
(2014) - et al.
Perfusion CT to quantify the cerebral vasospasm following subarachnoid haemorrhage
J Neuroradiol
(2010) - et al.
Diffusion-Weighted Imaging infarct volume and neurologic outcomes after ischemic stroke
J Neuroradiol
(2012) - et al.
Lower incidence of cerebral infarction correlates with improved functional outcome after aneurysmal subarachnoid hemorrhage
J Cereb Blood Flow Metab
(2011) - et al.
Predictors of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage
Neurosurgery
(2007) - et al.
Acute Ischemic Injury on Diffusion-Weighted Magnetic Resonance Imaging after Poor Grade Subarachnoid Hemorrhage
Neurocrit Care
(2011) - et al.
Cerebral vasospasm following subarachnoid hemorrhage: time for a new world of thought
Neurol Res
(2009)
Does prevention of vasospasm in subarachnoid hemorrhage improve clinical outcome? Yes
Stroke
Does prevention of vasospasm in subarachnoid hemorrhage improve clinical outcome? No
Stroke
Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) Randomized, Double-Blind, Placebo-Controlled Phase 2 Dose-Finding Trial
Stroke
Angiographic Vasospasm Is Strongly Correlated With Cerebral Infarction After Subarachnoid Hemorrhage
Stroke
Beyond Delayed Cerebral Vasospasm: Infarct Patterns in Patients with Subarachnoid Hemorrhage
Clin Neuroradiol
The Relationship Between Delayed Infarcts and Angiographic Vasospasm After Aneurysmal subarachnoid Hemorrhage
Neurosurgery
Risk Factors Associated with Cerebral Vasospasm following Aneurysmal Subarachnoid Hemorrhage
Neurol Med Chir (Tokyo)
Impairment of Cerebral Perfusion and Infarct Patterns Attributable to Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Prospective MRI and DSA Study
Stroke
Perfusion-diffusion mismatch in MRI to indicate endovascular treatment of cerebral vasospasm after subarachnoid haemorrhage
J Neurol Neurosurg Psychiatry
Relationship between vasospasm, cerebral perfusion, and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage
Neuroradiology
Relationship between Angiographic Vasospasm and Regional Hypoperfusion In Aneurysmal Subarachnoid Hemorrhage
Stroke
Quality of Life and Healthcare Resource Use Associated With Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage
Stroke
Effect of prophylactic transluminal balloon angioplasty on cerebral vasospasm and outcome in patients with Fisher Grade III subarachnoid hemorrhage: results of a Phase II multicenter, randomized, clinical trial
Stroke
Factors associated with the development of vasospasm after planned surgical treatment of aneurysmal subarachnoid hemorrhage
J Neurosurg
Asymptomatic versus symptomatic infarcts from vasospasm in patients with subarachnoid hemorrhage: serial magnetic resonance imaging
Neurosurgery
Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage
J Neurosurg
Cited by (6)
ENDOVASCULAR TREATMENT OPTIONS FOR CEREBRAL VASOSPASM AFTER SPONTANEOUS SUBARACHNOID HAEMORRHAGE
2020, Encyclopedia of Surgery: Volume 1: (22 Volume Set)Feasibility and safety of repeat instant endovascular interventions in patients with refractory cerebral vasospasms
2017, American Journal of NeuroradiologyDelayed infarction following aneurysmal subarachnoid hemorrhage: Can the role of severe angiographic vasospasm really be dismissed?
2016, Journal of NeuroInterventional SurgeryEndovascular treatment options for cerebral vasospasm after spontaneous subarachnoid haemorrhage
2016, Spontaneous Subarachnoid Haemorrhage: Well-Known and New Approaches