The effect of endovascular therapy for cerebral arterial spasm, its limitation and pitfalls

Safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment after subarachnoid hemorrhage

Balloon angioplasty is often performed for symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. Angioplasty of the anterior cerebral artery (ACA), however, is perceived to be a challenging endeavor and not routinely performed due to technical and safety concerns. Here, we evaluate the safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment. Patients with vasospasm following subarachnoid hemorrhage who underwent balloon angioplasty at our institution between 2011 and 2016 were retrospectively reviewed. All ACA angioplasty segments were analyzed for pre- and post-angioplasty radiographic measurements. The degree of vasospasm was categorized as mild (<25%), moderate (25-50%), or severe (>50%), and relative change in caliber was measured following treatment. Clinical outcomes following treatment were also assessed. Among 17 patients, 82 total vessel segments and 35 ACA segments were treated with balloon angioplasty. Following angioplasty, 94% of segments had increased caliber. Neurological improvement was noted in 75% of awake patients. There were no intra-procedural complications, but two patients developed ACA territory infarction, despite angioplasty treatment. We demonstrate that balloon angioplasty of the ACA for vasospasm treatment is safe and effective. Thus, ACA angioplasty should be considered to treat vasospasm in symptomatic patients recalcitrant to vasodilation infusion therapy.

Transluminal balloon angioplasty for symptomatic distal vasospasm refractory to medical therapy in patients with aneurysmal subarachnoid hemorrhage

BACKGROUND

Cerebral vasospasm (VSP) is a major cause of morbidity and mortality associated with subarachnoid hemorrhage. The current endovascular paradigm for VSP refractory to medical therapy is to perform angioplasty for proximal vessel VSP and vasodilator infusion for distal vessel VSP.

OBJECTIVE

To report our experience with a large series of balloon angioplasty for distal VSP refractory to medical therapy in patients with aneurysmal subarachnoid hemorrhage.

METHODS

This was a retrospective series of 32 patients with subarachnoid hemorrhage and symptomatic VSP refractory to medical therapy who were treated with balloon angioplasty for distal vessel VSP. Immediate angiographic results, procedure-related complications, and clinical outcomes were assessed.

RESULTS

From September 2001 to January 2010, 32 patients with symptomatic VSP refractory to medical therapy underwent angioplasty for distal arterial VSP. There were 26 women (81.3%); patients were 29 to 67 years of age. A total of 175 vessels were angioplastied (95 proximal and 80 distal). The only complication was rupture of an incompletely clipped aneurysm that was treated by immediate coiling and did not result in any clinical worsening. Repeated treatment was needed for 6 arteries (6 of 80, 7.5%). There were no procedure-related symptomatic complications. Good outcomes (modified Rankin Scale score ≤ 2) were observed in 23 of 28 patients (82.1%) with follow-up.

CONCLUSION

Balloon angioplasty for distal VSP is safe and effective and decreases the need for repeated intraarterial treatments seen with infusion of vasodilator.

Comparison between angioplasty using compliant and noncompliant balloons for treatment of cerebral vasospasm associated with subarachnoid hemorrhage

BACKGROUND

Considerable controversy exists regarding the choice of balloon used for performing angioplasty as treatment of cerebral vasospasm associated with subarachnoid hemorrhage.

OBJECTIVE

To determine the impact of compliant and noncompliant balloons on angiographic and clinical outcomes among patients with subarachnoid hemorrhage-related cerebral vasospasm.

METHODS

Consecutive patients with cerebral vasospasm who underwent balloon angioplasty were included. Patient characteristics, rate of angiographic recurrence, and occurrence of cerebral infarcts in the affected vessel distribution were compared between arteries treated using different balloons.

RESULTS

A total of 30 patients underwent a first-time angioplasty using compliant (n = 34) or noncompliant (n = 51) balloons. At admission, patients were classified Hunt and Hess grade I to III (n = 20) and Hunt and Hess grade IV to V (n = 10). Fisher grades in patients were I (n = 1), II (n = 3), III (n = 20), and IV (n = 6). No significant differences in the rate of angiographic recurrence (32% vs 53%; P = .14), need for repeat angioplasty (21% vs 20%; P = .97), and occurrence of cerebral infarcts in the affected arterial distribution (21% vs 10% P = .39) were observed with compliant and noncompliant balloons, respectively. Independent of the balloon type, a significant reduction in the need for repeat angioplasty was observed when the initial angioplasty resulted in a normal or supranormal diameter compared with a subnormal diameter (63.5% vs 36.5%; P = .01).

CONCLUSION

No clear difference was observed between compliant and noncompliant balloons for therapeutic angioplasty in preventing angiographic recurrence or the need for repeat angioplasty in patients with subarachnoid hemorrhage-related cerebral vasospasm. An immediate normal or supranormal vessel diameter after the first-time angioplasty resulted in a significant reduction in the need for repeat angioplasty.

Treatment options for cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Cerebral vasospasm occurs frequently after aneurysmal subarachnoid and contributes to delayed cerebral ischemia. In this article we address systematic problems with the literature on vasospasm and then review both established and experimental treatment options.

Intra-arterial nimodipine to treat symptomatic cerebral vasospasm following traumatic subarachnoid haemorrhage. Technical case report

Intra-arterial Nimodipine administration can be an effective alternative to papaverine or balloon angioplasty for the treatment of cerebral vasospasm refractory to medical therapy. It has been used for intractable vasospasm due to aneurysmal subarachnoid haemorrhage (SAH) with convincing results and no significant complications in small case series. This report describes of a patient with symptomatic and angiographically documented vasospasm following traumatic SAH which was refractory to maximal medical therapy and successfully treated with intra-arterial infusion of Nimodipine. This first reported technical note is with special reference to the nimodipine administration modalities, clinical and neuroradiological criteria of selection as well as the follow up of the patient.

The effect of intra-arterial papaverine on ECoG activity in the ketamine anesthetized rat

The opium alkaloid papaverine (PPV) causes vasodilatation of the cerebral arteries through direct action on smooth muscle that reduces the constriction of smooth muscle. Intra-arterial papaverine (IAP) has been used widely to increase the regional cerebral blood flow in order to reverse the cerebral vasospasm that occurs during endovascular procedures. IAP-induced seizures have been reported, although PPV has anticonvulsive effects. This study determined the effects of IAP on electrocorticography (ECoG) in the ketamine anesthetized rats. We used 24 Sprague-Dawley male rats weighing 200-250 g. The animals were divided randomly into four groups: three treatment groups (groups 1-3) and a control (group 4). Groups 1, 2, and 3 were given 1, 7, and 14 mg/kg IAP, respectively. The ECoG was compared across groups. Our results indicated that IAP did not cause seizures and that it decreased the frequency of ketamine-induced epileptiform activity in the 14 mg/kg group.

Endovascular surgery for ruptured aneurysms with vasospasm

SUMMARY

With the existence of vasospasm, it is recommended that direct clipping surgery for a ruptured aneurysm be delayed until its disappearance, but this may be associated with aneurysmal re-rupture resulting in a poor outcome for the patients. Indications for endovascular coil embolization in such cases are discussed. Since November in 2003, we have applied endovascular coil embolization in 11 consecutive patients with ruptured aneurysms and apparent vasospasm of the parent artery from two to 17 days (average: eight days) after initial subarachnoid hemorrhage. Three patients had aneurysmal re-rupture before treatment, but the other eight had only experienced the one episode of subarachnoid hemorrhage. With one exception, all endovascular procedures could be successfully performed, resulting in complete occlusion of aneurysms and remarkable dilatation of inserted spastic vessels without technical complications or aneurysmal re-rupture. For the one case of failure because of a tortuous artery, direct clipping surgery was performed after disappearance of vasospasm. Cerebral infarction occurred in four, but only one correlated with the distribution of catheterization, and neurological deficits had completely disappeared three months after the onset. This preliminary report concerning a small number of patients suggests that endovascular coil embolization is not contra-indicated for aneurysms with vasospasm requiring catheterization. A large study for confirmation is now warranted.

Vasospasm in aneurysmal subarachnoid hemorrhage: diagnosis, prevention, and management

Cerebral vasospasm is a major cause of morbidity and mortality associated with subarachnoid hemorrhage (SAH). Advances in neuroimaging and development of newer intraparenchymal monitoring devices have improved the prediction and diagnosis of cerebral vasospasm significantly. Recent experimental and clinical trials have increased the armamentarium of preventive and treatment strategies for cerebral vasospasm. Vasospasm refractory to medical therapy usually is treated endovascularly with percutaneous transluminal balloon angioplasty (PTA) for proximal vessel vasospasm and vasodilator infusion for distal vessel vasospasm. Although vasospasm usually does not recur after PTA, recurrence is frequent after vasodilator infusion. The development of newer microballoon catheters has led to improvements in treatment of not only proximal but also distal vessel vasospasm with balloon angioplasty. This article reports on current knowledge in the diagnosis, prediction, prevention, and management of cerebral vasospasm.

Endovascular Management of Cerebral Vasospasm

CEREBRAL VASOSPASM REMAINS a leading cause of death and disability in patients with ruptured cerebral aneurysms. The development of endovascular intervention in the past two decades has shown promising results in the treatment of vasospasm. Endovascular techniques that have been used in humans include intra-arterial infusion of vasorelaxants and direct mechanical dilation with transluminal balloon angioplasty. This article reviews the current indications and role of endovascular therapy in the management of cerebral vasospasm, its clinical significance, and potential future therapies.

Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine

Cerebral vasospasm is still one of the leading causes of morbidity and mortality from subarachnoid hemorrhage. Vasospasm refractory to medical management can be treated with endovascular therapies, such as transluminal balloon angioplasty or infusion of intra-arterial vasodilating agents. In our review of clinical series reported in the English language literature, transluminal balloon angioplasty produced clinical improvement in 62% of patients, significantly improved mean transcranial Doppler (TCD) velocities(P <.05), significantly improved cerebral blood flow (CBF) in 85% of patients as studied by (133)Xenon techniques and serial single photon emission computerized tomography,and was associated with 5.0% complications and 1.1% vessel rupture. Intra-arterial papaverine therapy produced clinical improvement in 43% of patients but only transiently,requiring multiple treatment sessions (1.7 treatments per patient); significantly improved mean TCD velocities (P <.01) but only for less than 48 hours; improved CBF in 60% of patients but only for less than 12 hours; and was associated with increases in intracranial pressure and 9.9% complications. Intra-arterial nicardipine therapy produced clinical improvement in 42% of patients, significantly improved mean TCD velocities (P <.001) for 4 days, and was associated with no complications in our small series. We have adopted a treatment protocol at our institution of transluminal balloon angioplasty and intra-arterial nicardipine therapy as the endovascular treatments for medically refractory cerebral vasospasm.

Efficacy of intra-arterial nimodipine in the treatment of cerebral vasospasm complicating subarachnoid haemorrhage

AIM

To examine the efficacy and safety of nimodipine as an alternative to papaverine for the treatment of cerebral vasospasm following subarachnoid haemorrhage.

METHODS

We retrospectively reviewed the procedure reports, anaesthetic records, clinical charts and CT and angiographic images of 9 patients who had received intra-arterial nimodipine; 1 of these patients received both nimodipine and papaverine. The difference in arterial luminal diameter before and after treatment was calculated as a percentage change.

RESULTS

The average dose of nimodipine administered per vessel was 3.3mg. The mean increase in arterial diameter was 66.6% in the vasospastic segment. There was no significant change in blood pressure of any of the subjects during endovascular treatment of vasospasm.

CONCLUSION

Intra-arterial nimodipine is effective in improving angiographic vasospasm complicating subarachnoid haemorrhage. Further studies aimed at examining the clinical benefits of nimodipine are warranted, particularly in view of the low risk of adverse side effects of nimopidine when compared with papaverine.

Cervical sympathetic block to reverse delayed ischemic neurological deficits after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The purpose of the present study was to evaluate the feasibility and safety of a locoregional cervical sympathetic block to improve cerebral perfusion in patients suffering from cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

METHODS

Nine consecutive patients with symptoms of delayed ischemic deficits, induced by angiographically confirmed cerebral vasospasm, were treated with the injection of locoregional anesthesia to block the ascending cervical sympathetic chain at the level of the superior cervical ganglion. Neurological status was recorded before and after the procedure, and cerebral angiography was performed before and after the procedure.

RESULTS

No complications occurred in this short series. The procedure appeared to be simple and safe. Horner's signs appeared within 12+/-0.1 minutes and lasted for an average of 6.3+/-4 hours. In all patients, improved cerebral perfusion was detected at the confirmatory angiography but without change in vessel caliber. One patient died of the complications of the initial hemorrhage, and 2 died of the consequences of the severe vasospasm despite maximal medical treatment. In all the other cases, the neurological status promptly returned to normal within 48 hours after the locoregional treatment.

CONCLUSIONS

Patients with mild to moderate symptoms seem to benefit greatly from transient ipsilateral cervical sympathetic block. This simple technique may be helpful when used as an adjunct to the standard therapy to improve cerebral perfusion.

The use of mild hypothermia for patients with severe vasospasm: a preliminary report

The purpose of this study was to determine the effect of mild hypothermia on cerebral ischaemia due to severe vasospasm, which was refractory to medical and intravascular treatments and to assess the brain protection of this treatment in patients who underwent delayed aneurysm clipping after presenting with ischaemic neurological deficits. Mild hypothermia (32-34 degrees C of brain temperature) was employed in two groups: (1) Patients (Hunt and Kosnik grades I to II) who showed progressive neurological deficits due to vasospasm and did not respond to conventional therapy (Group 1) and (2) Patients who received delayed aneurysm clipping after presenting with ischaemic neurological deficits due to vasospasm (Group 2). Seven of 8 patients in both Groups showed a favorable outcome with mild hypothermia (good recovery in 5 and moderate disability in two patients). Mild hypothermia is considered to be effective on critical cerebral ischaemia due to vasospasm even after failure to response the conventional therapies and to provide brain protection in delayed aneurysm clipping.

Indications for endovascular therapy for refractory vasospasm after aneurysmal subarachnoid hemorrhage: experience at the University of Cincinnati

BACKGROUND

Transluminal balloon angioplasty (TBA) and intra-arterial papaverine (IAP) appear to be valuable alternatives for the treatment of aneurysmal subarachnoid hemorrhage (SAH)-induced vasospasm refractory to maximal medical therapy. Although widely used, guiding principles for the implementation of TBA and IAP are not yet established. Based on our retrospective analysis, we define guidelines for endovascular therapy for refractory vasospasm based on our clinical results, adverse effects, and pattern of vasospasm.

METHODS

Medical records of 62 patients who experienced aneurysmal SAH-induced vasospasm refractory to hypervolemic, hypertensive, hyperdynamic therapy, and who were treated with IAP or TBA were reviewed. Fifty patients met the inclusion criteria for analysis. After careful scrutiny, two types of responses to endovascular treatment were identified. On the basis of that grouping, patients were divided into two groups according to the number of arterial segments involved, that is, monoterritorial and multiterritorial vasospasm. Multiple variables were analyzed.

RESULTS

Patients undergoing multiple endovascular procedures exhibited the worst outcomes. Patients in the monoterritorial group experienced a higher incidence of clinical improvement and better outcomes after endovascular treatment. Elevated intracranial pressure (ICP) and ICP-related deaths were more prominent in the multiterritorial group of patients. Sustained ICP elevation after administration of IAP was strongly associated with poor outcome in the multiterritorial group.

CONCLUSIONS

IAP is indicated as an early potential single-dose infusion in distal monoterritorial vasospasm, if angioplasty is impossible or unsafe. The use of IAP in bilateral diffuse vasospasm is discouraged because of the high susceptibility of these patients to develop elevated ICP. Multiple IAP infusions seem to have no significant impact on patient outcome. Balloon angioplasty seems to be indicated at an early juncture in patients with multiterritorial proximal vasospasm.

Intra-arterial papaverine-induced seizures: case report and review of the literature

BACKGROUND

Microcatheter-guided intra-arterial (IA) papaverine infusion in conjunction with balloon angioplasty is an available therapy for patients with symptomatic vasospasm after subarachnoid hemorrhage (SAH) that is refractory to hypertensive, hypervolemic therapy. However, side effects and complications have been reported in association with its use.

CASE DESCRIPTION

We report on a patient who developed symptomatic vasospasm after subarachnoid hemorrhage due to rupture of a left terminal internal carotid artery (ICA) saccular aneurysm. Seven days after the hemorrhage and 4 days after surgical clipping, the patient developed aphasia and right hemiparesis due to vasospasm, which was refractory to maximal medical treatment with volume and blood pressure elevation. Cerebral angiography identified severe narrowing of distal ICA and proximal middle cerebral artery segments bilaterally. These findings partially resolved after balloon angioplasty. However, after 300 mg of IA papaverine, the patient developed generalized convulsions. This occurred despite therapeutic serum levels of phenytoin. Twenty-four hours later, after brief neurologic improvement, recurrent neurologic deficits prompted repeat papaverine administration. Seizures again occurred after the administration of 240 mg of IA papaverine and prevented administration of the full dose. The patient did not develop further seizures and her neurologic deficits continue to resolve.

CONCLUSIONS

IA papaverine-induced seizures are infrequently reported. This potential complication should be considered when papaverine administration is entertained in the treatment of anterior circulation refractory symptomatic vasospasm after SAH.

Review of medical prevention of vasospasm after aneurysmal subarachnoid hemorrhage: a problem of neurointensive care

Cerebral vasospasm remains a devastating medical complication of aneurysmal subarachnoid hemorrhage (SAH). It is associated with high morbidity and mortality rates, even after the aneurysm has been secured surgically or radiologically. A great deal of experimental and clinical research has been conducted in an effort to find ways to prevent this complication. The literature includes extensive coverage of in vivo animal model studies of SAH and vasospasm. These experimental studies have contributed to tremendous advances in the understanding of the mechanisms leading to cerebral vasospasm. Most of the experimental settings, however, have demonstrated varying levels of ability to predict accurately what occurs in human SAH. Therefore, although animal models have been developed to test new therapies, most of the treatment effects have been shown to be less compelling when trials have been conducted in clinical settings. The interpretation of current literature is complicated further by the imprecise estimation of the incidence of cerebral vasospasm, which is due to various degrees of clinical expression, ranging from the absence of symptoms in the presence of increased blood flow velocities at transcranial Doppler or vessel diameter reduction at angiography to neurological manifestations of severe ischemic deficits. In addition, a change over time in the incidence pattern of human SAH and vasospasm, possibly related to improved surgical techniques and overall patient management, may have occurred. This topic review collects the relevant literature on clinical trials investigating prophylactic therapies for cerebral vasospasm in patients with aneurysmal SAH and emphasizes the need for large clinical trials to confirm the results derived from clinical experience. In addition, it points out some experimental therapies that may hold promise in future clinical trials to prevent the occurrence of vasospasm.

Angiographic cerebral circulation time before and after endovascular therapy for symptomatic vasospasm

AIM

To investigate the correlation between angiographic cerebral circulation time (CCT) and cerebral blood flow (CBF) evaluated by single photon emission computed tomography (SPECT) before and after endovascular treatment for symptomatic vasospasm.

MATERIALS AND METHODS

Seven patients with unilateral vasospasm as demonstrated by catheter angiography who underwent pre- and post-treatment SPECT were selected. All patients had angiographic vasospasm of unilateral middle cerebral artery (MCA). Eight vessels in seven patients underwent intra-arterial papaverine infusion and three vessels underwent percutaneous transluminal angioplasty. Angiographic CCT was defined as the interval from the first image in which contrast medium was visible at the origin of MCA to its disappearance from the cortical arteries in the MCA territory. In SPECT studies, the ischaemic degree in MCA territory was analysed by side to side comparison with calculating the asymmetry index (AI).

RESULTS

The pre-treatment mean CCT was 4.1 +/- 0.8 s. The mean CCT immediately after treatment was 2.7 +/- 0.5 s. In the control subjects (n = 15) with unruptured aneurysm, mean CCT was 3.5 +/- 0.2 s. The pre-treatment mean CCT was significantly prolonged compared with that in the control subjects (P = 0.02). The post-treatment mean CCT was significantly shortened compared with that in the control subjects (P = 0.001). The pre-treatment mean AI was 71.2 +/- 7.4%, and that immediately after treatment was 90.5 +/- 3.6%. AI increased in all territories treated with endovascular treatment; the mean change was 19.3%. Angiographic CCT was closely correlated with AI in both pre- (r = - 0.95) and post-treatment (r = - 0.79).

CONCLUSION

Measurement of CCT is useful in evaluating cerebral haemodynamics of endovascular treatments in patients with cerebral vasospasm.

Efficacy of transluminal angioplasty for the management of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage

OBJECT

Transluminal angioplasty has become a widely used adjunct therapy to medical management of symptomatic cerebral vasospasm following subarachnoid hemorrhage (SAH). Despite anecdotal reports of universal, angiographically confirmed reversal of vasospasm and high rates of clinical improvement, no rigorous examination of the efficacy of this procedure has been conducted. In this study the authors assess the efficacy of the aforementioned procedure.

METHODS

Thirty-eight patients enrolled as part of the North American trial of tirilazad in aneurysmal SAH underwent transluminal angioplasty for symptomatic cerebral vasospasm. Fifty-three percent of these patients showed good recovery or moderate disability based on their 3-month Glasgow Outcome Scale score. Among the 38 patients who underwent angioplasty, the severity and type of vasospasm, use of papaverine in addition to balloon angioplasty, timing of treatment, and dose of study drug did not have an effect on the outcome. The results of their neurological examinations improved in only four of the 38 patients immediately after the procedure. A conditional logistic regression analysis was performed in which these patients were compared with individuals matched for age, sex, dose of study drug, admission neurological grade, and modified Glasgow Coma Scale score at the time of angioplasty. No effect on favorable outcomes was found for this procedure.

CONCLUSIONS

Transluminal cerebral angioplasty is very effective in reversing angiographically confirmed vasospasm, and anecdotal reports of its clinical utility are numerous. However, in this report the authors conclude that its superiority to medical management for symptomatic cerebral vasospasm is questionable.

The prophylactic use of transluminal balloon angioplasty in patients with Fisher Grade 3 subarachnoid hemorrhage: a pilot study

OBJECT

Recent advances in neuroradiology have made it possible to dilate vasospastic human cerebral arteries after aneurysmal subarachnoid hemorrhage (SAH), but the time window is short and the success rate for reversal of delayed ischemic neurological deficits (DINDs) varies between 31% and 77%. In a dog model of vasospasm, transluminal balloon angioplasty (TBA) performed on Day 0 totally prevented the development of angiographically demonstrated narrowing on Day 7. Because the effect of preventive TBA in this animal model was better than any pharmacological treatment described previously for experimental vasospasm, the authors conducted a pilot trial in humans to assess the safety and efficacy of TBA performed within 3 days of SAH.

METHODS

The study group consisted of 13 patients with Fisher Grade 3 SAH who had a very high probability of developing vasospasm. In all patients, regardless of the site of the ruptured aneurysm, target vessels for prophylactic TBA were as follows: the internal carotid artery, A1 segment, M1 segment, and P1 segment bilaterally; the basilar artery; and one vertebral artery. Prophylactic TBA was considered satisfactory when it could be performed in at least two of the three parts of the intracranial circulation (right and/or left carotid system and/or vertebrobasilar system), and included the aneurysm-bearing part of the circulation. Of the 13 patients, none developed a DIND or more than mild vasospasm according to transcranial Doppler ultrasonography criteria. At 3 months posttreatment eight patients had made a good recovery, two were moderately disabled, and three had died; one patient died because of a vessel rupture during TBA and two elderly individuals died of medical complications associated with poor clinical condition on admission.

CONCLUSIONS

Compared with large series of patients with aneurysmal SAH reported in the literature, the results of this pilot study indicate an extremely low incidence of vasospasm and DIND after treatment with prophylactic TBA. A larger randomized study is required to determine whether prophylactic TBA is efficacious enough to justify the risks, and which vessels need to be dilated prophylactically.

Accentuated Vasospasm during Treatment of an Acutely Ruptured Aneurysm with Electrolytically Detachable Coils: Coincidence or Causation?

We report an unusual case of precipitous worsening of vasospasm associated with subarachnoid haemorrhage that developed during endosaccular coil embolisation of a ruptured posterior communicating aneurysm. The acutely worsening vasospasm occurred in the distal ipsilateral anterior circulation remote from the site of microcatheter manipulation, resulting in transient occlusion. Despite successful endovascular treatment of both the aneurysm and vasospasm, the patient continued to clinically decline and eventually died. This case raises important issues regarding the potential mechanisms and optimal therapeutic strategies for this complication, which are reviewed.

Safety and efficacy of transluminal balloon angioplasty in the prevention of vasospasm in patients with Fisher Grade 3 subarachnoid hemorrhage: a pilot study

Recent advances in neuroradiology have made it possible to dilate human cerebral arteries that show vasospasm following aneurysmal subarachnoid hemorrhage (SAH), but the time window is short and the success rate for reversal of delayed ischemic neurological deficit (DIND) varies between 31% and 77%. In a canine model of vasospasm, transluminal balloon angioplasty (TBA) performed on Day 0 (the day of aneurysm rupture) has been shown to completely prevent the development of angiographically demonstrated narrowing by Day 7; this effect is better than any pharmacological treatment for vasospasm thus far described.

The authors conducted a pilot trial to assess the safety and efficacy of TBA performed within 3 days post-SAH. Twelve patients with a very high probability of developing vasospasm (Fisher Grade 3) were included. Target vessels for prophylactic TBA were the internal carotid artery, A1 segment, M1 segment, and P1 segment bilaterally, the basilar artery, and the vertebral artery.

No patient developed DIND or more than mild vasospasm, according to transcranial Doppler criteria. At 3 months, seven patients made a good recovery, two patients were moderately disabled, and three patients died; one patient died because of a vessel rupture during TBA and two older patients died of medical complications associated with an already poor clinical condition at admission.

Compared with the results of large series reported in literature of patients with aneurysmal SAH, the results of this pilot study indicate an extremely low incidence of vasospasm and DIND after patients underwent prophylactic TBA. A larger, randomized study, however, is required to determine whether prophylactic TBA is efficacious enough to justify the risks.