Distal Balloon Angioplasty of Cerebral Vasospasm Decreases the Risk of Delayed Cerebral Infarction

M.-A. Labeyrie; S. Gaugain; G. Boulouis; A. Zetchi; J. Brami; J.-P. Saint-Maurice; V. Civelli; S. Froelich; E. Houdart

doi:10.3174/ajnr.A6124

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Fig 1.
Anatomic definition of distal-versus-proximal balloon angioplasty. Frontal (A and C) and lateral (B and D) angiograms of the right internal carotid artery before cerebral vasospasm. Arterial segments treated using proximal balloon angioplasty are indicated in A and B (intra-arterial white line). They include the terminal internal carotid artery and the main segments of cerebral arteries up to the end of their first segment (single star for A1, double star for M1). Arterial segments treated using distal balloon angioplasty are shown in C and D (intra-arterial white line). They include the terminal internal carotid artery and the main segments of the cerebral arteries up to the end of their second segments (single arrowhead for pericallosal segment, double arrowhead for the anterior M2 branch, and triple arrowhead for the posterior M2 branch).
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Fig 2.
Distal balloon angioplasty in a 1.5-mm large M2 segment using an extracompliant 4-mm-large and 7-mm-long remodeling balloon. After we navigated in the distal M2 with a 0.010-inch guidewire, the balloon was positioned (A) and inflated progressively (B and C). The balloon has first a fusiform aspect (B) and then a tubular aspect and elongates (C) when it reaches the maximal diameter of the vessel. The balloon was immediately deflated. This maneuver was repeated within the entire segment from the proximal-to-distal M2.
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Fig 3.
An example of distal transluminal balloon angioplasty of the anterior and posterior M2 branches of the right middle cerebral artery (same patient as in Fig 1). Front (A–C) and lateral (D–F) angiograms of the right internal carotid artery. DSA before angioplasty (B and E) shows a severe vasospasm (60%) of M1 (double star) and the anterior (double arrowhead) and posterior (triple arrowhead) M2 branches, with distal delayed enhancement compared with DSA before vasospasm (A and D), which is cured after a distal balloon angioplasty procedure (C and F).

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Table 1:

Baseline characteristics of patients with aSAH

	Total (N = 392)	Period 1 (n = 160)^{^a}	Period 2 (n = 232)^{^a}	P Value
Age (range) (yr)	52 (44–61)	52 (44–62)	52 (46–61)	.9
Female (No.) (%)	254 (65%)	104 (65%)	150 (65%)	.5
Tobacco (No.) (%)	188 (48%)	75 (47%)	113 (49%)	.4
Chronic high blood pressure (No.) (%)	168 (43%)	76 (47%)	92 (40%)	.1
Dyslipidemia (No.) (%)	84 (21%)	36 (22%)	48 (21%)	.6
Diabetes mellitus (No.) (%)	19 (5%)	9 (6%)	10 (4%)	.3
Modified Fisher grade
1, 2 (No.) (%)	73 (19%)	34 (21%)	39 (17%)	.3
3 (No.) (%)	103 (26%)	37 (23%)	66 (28%)	.2
4 (No.) (%)	216 (55%)	89 (56%)	127 (55%)	.8
WFNS
I, II (No.) (%)	270 (69%)	105 (65%)	165 (71%)	.2
III (No.) (%)	22 (6%)	11 (7%)	13 (6%)	.6
IV (No.) (%)	56 (14%)	22 (14%)	32 (14%)	1
V (No.) (%)	44 (11%)	22 (14%)	22 (9%)	.2

↵a Period 1/period 2 (before/after January 2015) means chemical/balloon angioplasty as a first-line treatment of distal vasospasm.

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Table 2:

Intensive therapies of vasospasm in patients with aSAH

	Total (N = 392)	Period 1 (n = 160)^{^a}	Period 2 (n = 232)^{^a}	P Value
Intensive treatment of vasospasm (No.) (%)	155 (40%)	47 (29%)	108 (46%)	<.001
Angioplasty (No.) (%)	145 (37%)	44 (27%)	101 (43%)	.001
Distal angioplasty (No.) (%)^{^b}	109 (28%)	35 (22%)	74 (32%)	.029
Distal balloon angioplasty (No.) (%)^{^c}	87 (22%)	13 (8%)	74 (32%)	<.001
Proximal balloon angioplasty (No.) (%)^{^d}	91 (23%)	26 (16%)	65 (28%)	.004
Chemical angioplasty (No.) (%)^{^d}	36 (9%)	31 (19%)	5 (2%)	<.001
Intravenous milrinone (No.) (%)	86 (22%)	15 (9%)	71 (31%)	<.001

↵a Period 1/period 2 (see Table 1).
↵b Distal angioplasty means distal balloon angioplasty or chemical angioplasty.
↵c Distal balloon angioplasty was performed alone.
↵d Chemical and proximal balloon angioplasties were performed alone or combined.

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Table 3:

Outcome of patients with aSAH

	Total (N = 392)	Period 1 (n = 160)^{^a}	Period 2 (n = 232)^{^a}	P Value
Complications of angioplasty
Cerebral infarction (No.) (%)	10 (2.5%)	4 (2.5%)	6 (2.6%)	1
Intracranial hemorrhage (No.) (%)	4 (0.7%)	1 (0.6%)	3 (1.3%)	.64
Malignant edema (No.) (%)	4 (1%)	4 (2.5%)	0 (0)	.02
DCIn
DCIn (No.) (%)	38 (9.6%)	20 (12.5%)	18 (7.7%)	.11
Postangioplasty DCIn (No.) (%)	17 (4.3%)	12 (7.5%)	5 (2.2%)	.01
DCIn without angioplasty (No.) (%)	26 (6.6%)	12 (7.5%)	14 (6.0%)	.27
New angioplasty (No.) (%)	49 (12%)	30 (19%)	19 (8%)	.002
1-Month death (No.) (%)	42 (11%)	18 (11%)	24 (10%)	.45
6- to 12-Month mRS ≤ 2 (No.) (%)	300 (76%)	117 (73%)	183 (79%)	.12

↵a Period 1/period 2 (see Table 1).

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Table 4:

Comparative outcome with recent studies^{^a}

	Fisher ≥ 3	WFNS < IV	DCIn	Angioplasty/Approach	mRS ≥ 4	Death
Our study (N = 232)	83%	77%	8%	42%/Distal balloon angioplasty	17%	10%
Matsuda et al 2016²⁰ (N = 74)	NA	92%	11%	18%/Conventional	18%	NA
Macdonald et al 2012¹⁹ (N = 189)	>85%	84%	13%	21%/Conventional	24%	6%
Santillan et al 2011⁸ (N = 32)^{^b}	65%	60%	NA	100%/Distal balloon angioplasty	17%	0%

Note:—NA indicates not applicable.
↵a Our results during the second period (with distal balloon angioplasty) were compared with those in the series of Santillan et al⁸ and control groups of recent randomized aSAH trials.
↵b Only patients who had an angioplasty of vasospasm were included.