Treatment of cerebral vasospasm with self-expandable retrievable stents: proof of concept

Stent Angioplasty for the Treatment of Cerebral Vasospasm: A Systematic Review and Meta-Analysis

BACKGROUND

Several case series and prospective cohorts have reported the use of stent retrievers (SR) and specifically designed expanding stents (ES) to perform in situ mechanical stent angioplasty to treat cerebral vasospasm in subarachnoid vasospasm.

PURPOSE

The aim of this study was to review and conduct a meta-analysis to evaluate the safety and efficacy of this novel technique.

DATA SOURCES

A systematic review and meta-analysis was conducted according to established protocols. Searches were conducted in PubMed, Scopus, Web of Science, and EMBASE databases up to June 2024, including variations of "stent," "expanding device," "vasospasm," "subarachnoid hemorrhage." Original studies reporting treatment outcomes for vasospasm by using SR/ES in more than 5 patients were included.

STUDY SELECTION

Pooled data from 8 studies, comprising 156 patients and 428 targeted vessels treated with stent angioplasty for vasospasm were analyzed.

DATA ANALYSIS

We evaluated rates of angiographic success, complications, recurrence, and neurologic improvement. Meta-analysis was performed by using a random-effects model.

DATA SYNTHESIS

The angiographic success rate was 81.8% (95% CI: 70.6-89.3). Subgroup analysis showed a success rate of 86.5% (95% CI: 62.6-96.1) with ES and 80.5% (95%CI: 62.6-93.1) with SR. Overall complication rate was 1.1% (95% CI: 0.0-3.6), due to clot formation or hemorrhage. Recurrence of vasospasm was noted in 12.8% (95% CI: 5.2-28.1) while neurologic improvement was seen in 65.9% (95% CI: 51.1-78.1) of the cases. Finally, it should be noted that all included studies used stent angioplasty in combination with intra-arterial vasodilators.

LIMITATIONS

Our meta-analysis is limited by selection and reporting biases, as well as high heterogeneity. Moreover, the overall low quality of available evidence is the main limitation of our results.

CONCLUSIONS

Combination of stent angioplasty and intra-arterial vasodilators was found to have high rates of angiographic success and low incidences of adverse events. Randomized controlled trials are needed to confirm their efficacy and safety compared with medical and balloon angioplasty treatments.

Functional outcomes following endovascular treatment of vasospasm secondary to aneurysmal subarachnoid Hemorrhage: A Single center retrospective analysis

INTRODUCTION

Endovascular treatment of post-hemorrhagic cerebral vasospasm (PHCV) has the potential to improve functional outcomes but there continues to be limited data reported in the literature.

OBJECTIVE

To retrospectively review our institution's experience treating PHCV endovascularly and report clinical outcome data.

METHODS

Patients who experienced nontraumatic subarachnoid hemorrhage (SAH) and were treated with endovascular therapy were identified using ICD and CPT codes. Demographic, clinical, and outcome variables were then collected via review of electronic medical records. The primary outcome measure was rate of modified Rankin Score (mRS) ≤ 2 at discharge as well as 1, 3, and 6 months after discharge. Discharge disposition, angiographic response to treatment, and complication rates were secondary outcomes. A subgroup analysis was performed on patients treated with retrievable stents.

RESULTS

In a 12.5 year period, 1396 patients with nontraumatic SAH were treated, and of these 82/1396 (5.9 %) were treated endovascularly for vasospasm. 200 total interventions were performed on 82 patients. 29.7 % of patients had radiographic delayed cerebral ischemia. The complication rates were 3.5 % per procedure and 4.9 % per patient. 40.7 % of patients had good neurologic outcomes (mRS ≤ 2) at any time point. In-hospital mortality was 11 % and 6-month mortality was 21 %. Higher presenting Glasgow Coma Score (GCS) predicted good neurologic outcome in univariable logistic regression (OR = 1.33, p = 0.026). Patients that underwent mechanical angioplasty were significantly younger than those who did not (46 years vs 53 years, p = 0.003). 11 cases of retrievable stent angioplasty were performed, yielding a complication rate of 9 % which was comparable to the complication rate of patients treated with balloon angioplasty (4.3 %, p = 0.54).

CONCLUSIONS

Our experience with endovascular treatment of PHCV results in similar functional outcomes and complication rates to the literature. Better presenting GCS predicts good functional outcomes in patients with PHCV treated endovascularly. Patients undergoing mechanical angioplasty tended to be younger. Retrievable stents produced similar rates of complications and good functional outcomes to balloon angioplasty patients.

Sustained efficacy of angioplasty for cerebral vasospasm after aneurysmal subarachnoid hemorrhage: Risk features and device comparison

BACKGROUND

Cerebral vasospasm is a leading source of delayed morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Angioplasty may improve vasospasm, while optimal target and device selection remains controversial. This study aimed to identify features and devices associated with sustained efficacy.

METHODS

We identified consecutive patients who underwent angioplasty for aSAH vasospasm. The primary outcome was a composite of adequate angioplasty (residual narrowing < 50 %) without complications. Secondary outcomes included rates of refractory/recurrent vasospasm and sustained improvement at follow-up. Associated features were identified through multivariable analysis. Outcomes were compared between balloon and Comaneci/stentriever in a propensity-score-matched cohort.

RESULTS

A total of 149 vasospastic segments underwent angioplasty: 61.7 % in the proximal anterior circulation (ICA, M1, A1), 20.1 % in distal segments (A2 and M2) and 18.1 % in the posterior circulation. Adequate angioplasty was achieved without complication in 83.2 % of vessels, with a sustainable effect in 84.3 % at follow-up. Refractory/recurrent vasospasm was observed in 17.4 %, yielding a 10.1 % retreatment rate. Notably, only 35.3 % of vessels undergoing inadequate angioplasty demonstrated improvement at follow-up. Angioplasty targeting distal MCA (adjusted OR, 0.10) or BA-V4 (aOR, 0.10), and inadequate angioplasty (aOR, 0.03) were unfavorable predictors for sustained improvement. Efficacy outcomes were similar between balloon and Comaneci/stentriever in a matched subgroup analysis.

CONCLUSION

Angioplasty, when achieving residual narrowing < 50 %, demonstrated sustained improvement for vasospasm. Novel devices may exhibit comparable efficacy to balloon angioplasty for selected segments.

Is Stent Retraction to ReLieve Arterial Cerebral VaSospasm Caused by SAH (Stent-ReLACSS) Using PRELAX the Long-awaited Solution for Treatment of Posthemorrhagic Cerebral Vasospasm? : Treatment of Posthemorrhagic Cerebral Vasospasm with PRESET and PRELAX: Technical Aspects, Efficacy, and Safety Margins in a Case Series

PURPOSE

Recent observational studies have indicated the efficacy of stent retriever devices for the treatment of posthemorrhagic cerebral vasospasm (CVS), both by deployment and on-site withdrawal into the microcatheter (stent angioplasty, SA) and deployment followed by retraction through the target vessel similar to thrombectomy (Stent Retraction to reLieve Arterial Cerebral vaSospasm caused by SAH, Stent-ReLACSS). This article reports the findings with each application of pRESET and pRELAX in the treatment of CVS.

METHODS

We retrospectively enrolled 25 patients with severe CVS following aneurysmal subarachnoid hemorrhage. For the SA group, a stent retriever or a pRELAX was temporarily deployed into a narrow vessel segment and retrieved into the microcatheter after 3 min. For the Stent-ReLACSS group, a pRELAX was temporarily deployed into a narrow vessel and pulled back unfolded into the internal carotid artery. If intra-arterial vasodilators were administered, they were given exclusively after mechanical vasospasmolysis to maximize the effectiveness of the stent treatment.

RESULTS

In this study fifteen patients and 49 vessels were treated with SA. All were technically successful without periprocedural complications; however, 8/15 patients (53.3%) required additional treatment of the CVS. A total of 10 patients and 23 vessel segments were treated with Stent-ReLACSS. All maneuvers were technically successful without periprocedural complications and all vessels showed significant angiographic improvement. No recurrent CVS requiring further endovascular treatment occurred in-hospital, and neither territorial ischemia in the treated vessels nor vascular injury were observed in follow-up angiography.

CONCLUSION

Based on the presented data it appears that Stent-ReLACSS with pRELAX does not pose any additional risks when used to treat CVS and might be superior to SA, especially concerning mid-term and long-term efficacy. The mechanism of action may be an effect on the endothelium rather than mechanical vasodilation. As many patients with CVS are diagnosed too late, prophylactic treatment of high-risk patients (e.g., poor grade, young, female) is potentially viable.

Use of a stent-retriever for treatment of iatrogenic vasospasm secondary to mechanical thrombectomy

The treatment strategy for iatrogenic intracranial vasospasm has not been established. We reported a rare case of stent-retriever use for the treatment of iatrogenic vasospasm after mechanical thrombectomy. The patient presented acute ischemic stroke due to the occlusion of the left middle cerebral artery (MCA). The patient underwent a successfully mechanical thrombectomy, however, severe stenosis was visualized in MCA, which was considered to be an iatrogenic mechanical vasospasm. This vasospasm was successfully treated with the Solitaire stent device, and the patient recovered from ischemic symptoms. A stent-retriever is a safe and effective treatment for iatrogenic vasospasm after mechanical thrombectomy.

Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes.

METHODS

A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed.

RESULTS

Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation.

CONCLUSIONS

A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.

COManeci MechANical Dilation for vasospasm (COMMAND): multicenter experience

BACKGROUND

We report the largest multicenter experience to date of utilizing the Comaneci device for endovascular treatment of refractory intracranial vasospasm.

METHODS

Consecutive patients undergoing Comaneci mechanical dilatation for vasospasm were extracted from prospectively maintained registries in 11 North American centers (2020-2022). Intra-arterial vasodilators (IAV) were allowed, with the Comaneci device utilized after absence of vessel dilation post-infusion. Pre- and post-vasospasm treatment scores were recorded for each segment, with primary radiological outcome of score improvement post-treatment. Primary clinical outcome was safety/device-related complications, with secondary endpoints of functional outcomes at last follow-up.

RESULTS

A total of 129 vessels in 40 patients (median age 52 years; 67.5% females) received mechanical dilation, 109 of which (84.5%) exhibited pre-treatment severe-to-critical vasospasm (ie, score 3/4). Aneurysmal subarachnoid hemorrhage was the most common etiology of vasospasm (85%), with 65% of procedures utilizing Comaneci-17 (92.5% of patients received IAV). The most treated segments were anterior cerebral artery (34.9%) and middle cerebral artery (31%). Significant vasospasm drop (pre-treatment score (3-4) to post-treatment (0-2)) was achieved in 89.9% of vessels (96.1% of vessels experienced ≥1-point drop in score post-treatment). There were no major procedural/post-procedural device-related complications. Primary failure (ie, vessel unresponsive) was encountered in one vessel (1 patient) (1/129; 0.8%) while secondary failure (ie, recurrence in previously treated segment requiring retreatment in another procedure) occurred in 16 vessels (7 patients) (16/129; 12.4%), with median time-to-retreatment of 2 days. Favorable clinical outcome (modified Rankin Scale 0-2) was noted in 51.5% of patients (median follow-up 6 months).

CONCLUSIONS

The Comaneci device provides a complementary strategy for treatment of refractory vasospasm with reasonable efficacy/favorable safety. Future prospective trials are warranted.

Distal cerebral vasospasm treatment following aneurysmal subarachnoid hemorrhage using the Comaneci device: technical feasibility and single-center preliminary results

BACKGROUND

Balloon-assisted mechanical angioplasty for cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) has a number of limitations, including transient occlusion of the spastic blood vessel. Comaneci is an FDA-approved device for temporary coil embolization assistance which has recently also been approved for the treatment of distal symptomatic refractory vasospasm. We aimed to report the feasibility, efficacy and safety of our experience with Comaneci angioplasty for refractory distal vasospasm (up to the second segment of the cerebral arteries) following aSAH.

METHODS

This is a retrospective analysis of a prospective series of 18 patients included between April 2019 and June 2021 with aSAH and symptomatic vasospasm refractory to medical therapy, who were treated using Comaneci-17-asssisted mechanical distal angioplasty. Immediate angiographic results, procedure-related complications, and clinical outcomes were assessed. Inter-rater reliability of the scores was determined using the intraclass correlation coefficient.

RESULTS

Comaneci-assisted distal angioplasty was performed in 18 patients, corresponding to 31 target arteries. All distal anterior segments were easily accessible with the Comaneci-17 device. Vasospasm improvement after Comaneci mechanical angioplasty was seen in 22 distal arteries (71%) (weighted Cohen's kappa (κ_w) 0.73, 95% CI 0.69 to 0.93). Vasospasm recurrence occurred in three patients (16.67%) and delayed cerebral infarction in three patients (16.67%), with a mean±SD delay between onset of symptoms and imaging follow-up (MRI/CT) of 32.61±8.93 days (κ_w 0.98, 95% CI 0.88 to 1).

CONCLUSION

This initial experience suggests that distal mechanical angioplasty performed with the Comaneci-17 device for refractory vasospasm following aSAH seems to be safe, with good feasibility and efficacy.

Intracranial stenting as a bail-out option for posthemorrhagic cerebral vasospasm: a single-center experience with long-term follow-up

Background

Cerebral vasospasm (CVS) is a leading cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage (aSAH). Endovascular treatment, including intraarterial infusion of drugs with vasodilation effects, and balloon- and stentriever angioplasty, are helpful but may achieve only short-term effects. There is a clinical need for long-lasting treatment of refractory recurrent vasospasm. We report our experience in stent implantation as a treatment for recurrent severe post-SAH vasospasm.

Methods

A retrospective analysis of our institutional database of 883 patients with SAH, managed between January 2010 and December 2021, was performed. Six patients were identified as having received intracranial stenting in the context of post-SAH cerebral vasospasm. All patients were initially treated with intra-arterial infusion of nimodipine and/or milrinone. Self-expanding intracranial stents were implanted during endovascular aneurysm treatment to enable access despite impaired perfusion (Group 1) or as a bail-out strategy after failed intraarterial drug infusion or mechanical treatment (Group 2). All stented patients received dual antiplatelet therapy (DAPT) for 6 months.

Results

Nine vessels in six patients with severe post-SAH vasospasm were stented. The stents were deployed in 16 vessel segments. All attempted implantations were technically successful. All patients demonstrated radiographic and clinical improvement of the vessel narrowing. No recurrent vasospasm or permanent vessel occlusion of the stented vessels was encountered. A thrombus formation in a Group 1 patient resolved under 4 mg eptifibatide IA infusion. During long-term angiographic follow-up, neither in-stent stenosis nor stent occlusion was found.

Conclusions

Endovascular implantation of self-expanding stents is a potential ultima ratio strategy for patients with severe refractory post-SAH cerebral vasospasm. Stents with reduced thrombogenicity (avoiding DAPT) and bioabsorbable self-expanding stents might further advance this concept.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02862-4.

Vasospasm-Related Death after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Case-Control Study

BACKGROUND

Vasospasm after the rupture of an intracranial aneurysm is a frequent phenomenon and is the main cause of morbidity and mortality in patients who have survived intracranial hemorrhage and aneurysm treatment. We analyzed the diagnosis and management of patients with aneurysmal subarachnoid hemorrhage who eventually died from ischemic brain damage due to vasospasm.

METHODS

Between January 2007 and December 2021 (15 years), a total of 1064 patients were diagnosed with an aneurysmal intracranial hemorrhage in a single comprehensive neurovascular center. Vasospasm was diagnosed in 408 patients (38.4%). A total of 187 patients (17.6%) died within 90 days of the aneurysm rupture. In 64 of these 187 patients (33.7%), vasospasm was considered to be the cause of death. In a retrospective analysis, demographic and clinical data for patients without, with non-fatal, and with fatal vasospasm were compared. The patients with fatal vasospasm were categorized into the following subgroups: "no diagnosis and treatment" (Group a), "delayed diagnosis" (Group b), "cardiovascular complications" (Group c), and "vasospasm-treatment complications" (Group d).

RESULTS

Among the patients with fatal vasospasm, 31 (48.4%) were assigned to group a, 26 (40.6%) to group b, seven (10.9%) to group c, and none (0%) to group d.

CONCLUSION

The early recognition of severe posthemorrhagic vasospasm is a prerequisite for any treatment and requires routine diagnostic imaging in all unconscious patients. Aggressive endovascular vasospasm treatment may fail to prevent death but is infrequently the cause of a fatal outcome.

Delayed cerebral ischemia: A look at the role of endothelial dysfunction, emerging endovascular management, and glymphatic clearance

Delayed cerebral ischemia (DCI) contributes to extensive morbidity and mortality for patients with aneurysmal subarachnoid hemorrhage (SAH). Recent contributions to the basic and translational investigation of DCI have shed light on emerging concepts that may aid in the development of novel therapeutics. A clear association between cerebral vasospasm (CV) and DCI exists, but it is also known that DCI can affect brain parenchyma remote from sites of vasospasm. In this review, we highlight the most recent contributions to the understanding of the underlying pathophysiology of DCI including the emerging role of the glymphatic system. Furthermore, we discuss treatments for DCI, including both pharmacologic therapies and endovascular treatment of vasospasm. There continues to be a disconnect between interventions and targeted treatment against pathophysiology. This review is intended to serve as a catalyst for further research and discovery that can aid in improved treatment options for DCI.

Large practice variations in diagnosis and treatment of delayed cerebral ischemia after subarachnoid hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI) contributes to poor outcomes after subarachnoid hemorrhage (SAH). The pathophysiology of DCI is not fully understood, which has hindered the adoption of a uniform definition. Furthermore, a reliable diagnostic test and an effective evidence-based treatment are lacking. This could lead to variations in care.

METHODS

A web-based survey on the variations in the definition, diagnosis, and treatment of DCI was designed and sent to 314 intensivists, neurologists, and neurosurgeons of all 9 hospitals in the Netherlands who care for patients with SAH. The responders were categorized into physicians responsible for the coordination of SAH care and those who were not. For questions on the definition and diagnosis, only the responses from the coordinating physicians were evaluated. For the treatment questions, all the responses were evaluated.

RESULTS

The response rate was 34% (106 of 314). All 9 hospitals were represented. Of the responses, 27 did not provide answers for the definition, diagnosis, or treatment questions; 79 responses were used for analysis. Signs of vasospasm were required by 21 of the 47 coordinating physicians (44%) when considering DCI. Of the 47 coordinating physicians, 24 (51%) did not use a diagnostic test results for a positive diagnosis of DCI. When patients were discharged within 21 days, 33 of the 73 responders (45%) did not provide a prescription for nimodipine continuation. Finally, all but one hospital had treated DCI with hypertension induction.

CONCLUSIONS

We found large variations in the definition, diagnosis, and treatment of DCI in the Netherlands. In the absence of evidence-based treatment, standardization of management seems warranted in an effort to optimize DCI care.

Use of the Cascade expandable net to treat cerebral vasospasm - initial clinical experience from a single centre with in vitro benchside tests

Background

The use of self-expanding stents to treat post-hemorrhagic cerebral vasospasm was recently described. We sought to determine the clinical efficacy of the Cascade device to treat delayed cerebral vasospasm (DCV). We performed benchside tests to determine the chronic outward force exerted by the Cascade in comparison to the Solitaire.

Methods

The chronic outward force (COF) of the Cascade M agile and Cascade L Agile was tested with equivalent tests of the Solitaire 4x20mm. Further tests to determine the forces generated in pre-formed tubes of 1.5–6 mm were performed using both fully and partially unsheathed Cascades.

A retrospective review to identify all patients with aSAH and DCV treated with a Cascade device between January 2020 and July 2021. We recorded the treatment arterial vessel diameters and hemorrhagic or ischemic complications.

Results

In vitro the Cascade generated greater radial force than the Solitaire. The force generated by the Cascade M Agile at 1.5 mm was approximately 64% higher than the Solitaire 6x40mm and approximately 350% higher than the Solitaire 4x20mm.

4 patients with DCV were identified all of whom were treated with a cascade device. In all cases there was a significant improvement in the diameter of the vasospastic vessels treated with an average diameter increase of approximately 300%. There were no complications from the Cascade. Delayed CT angiography showed persistent dilatation of the segments treated with the Cascade at 24 h.

Conclusion

The Cascade is a safe and effective device when used to treat DCV secondary to aSAH. Larger studies are required to validate our initial results.

Primary results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following Aneurysm Subarachnoid Hemorrhage (VITAL) Study

BACKGROUND

Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is linked to worse neurological outcomes. The NeVa VS is a novel cerebral dilation device based on predicate stent retrievers. We report the results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following aSAH (VITAL) Study.

METHODS

This was a single-arm prospective multicenter trial to assess the safety and probable benefit of the NeVa VS device to treat CV. Patients were screened and treated if they had CV >50% on non-invasive imaging confirmed by cerebral angiography. The vessel diameters were measured before and after treatment by an independent core laboratory. The primary endpoint was ≥50% vessel diameter immediately after treatment with the NeVa VS device.

RESULTS

Thirty patients with a mean age of 52±11 years and mean Hunt-Hess grade of 3.1±0.9 were enrolled. A total of 74 vessels were treated with an average of 1.3 deployments per vessel (95 deployments total). The mean pre-treatment narrowing of the target vessel (n=74) was 65.6% with reduction of the narrowing to 29.4% after treatment. The primary endpoint was achieved in 64 of 74 vessels (86.5%). In three of 95 total deployments (3.2%), thrombus at the site of deployment was observed during the procedure without apparent neurological sequelae.

CONCLUSIONS

The NeVa VS device appears to be a safe treatment to regain vessel diameter in severely narrowed intracranial arteries secondary to CV associated with aSAH. This treatment offers a new tool that allows for controlled vessel expansion to treat CV.

Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device

Delayed cerebral ischemia due to vasospasm following subarachnoid hemorrhage continues to have high morbidity and mortality despite current treatments. This report highlights the use of the Comaneci (Rapid Medical, Yokneam, Israel), a device FDA approved for temporary coil embolization assistance, for the treatment of symptomatic vasospasm. Ten days post subarachnoid hemorrhage, a patient developed acute left-sided hemiparesis with angiographic vasospasm. Through a Headway 17 microcatheter, a Comaneci 17 was deployed in the right ICA terminus, M1, M2, A1, and, A2 segments resulting in improvement of angiographic vasospasm and the patient's left-sided hemiparesis. On the following day, a repeat angiogram demonstrated no recurrence of vasospasm. The patient had complete return on neurologic function by post bleed day 18 continuing to her four-week follow-up appointment. This case demonstrates the feasibility of the Comaneci device as an effective tool in the treatment of vasospasm following subarachnoid hemorrhage.

Angioplasty with a retrievable stent to treat vasospasm secondary to subarachnoid hemorrhage due to an aneurysm: a multicenter study of safety and efficacy

OBJECTIVE

To determine the safety and efficacy of angioplasty with a retrievable stent in treating vasospasm secondary to subarachnoid hemorrhage (SAH) due to an aneurysm.

METHODS

We retrospectively analyzed prospectively collected data from consecutive patients undergoing endovascular angioplasty with a retrievable stent to treat vasospasm related to SAH due to an aneurysm in four neurointerventional radiology departments between January 2018 and July 2019. We included patients aged>18 years with vasospasm>50% of the internal carotid artery (ICA), anterior cerebral artery (ACA), and / or middle cerebral artery (MCA) secondary to SAH due to an aneurysm treated with endovascular angioplasty with a retrievable stent. The variables used to measure safety were complications of the procedure and clinical complications. The variables used to measure radiological efficacy were improvement in the degree of stenosis after endovascular treatment and improvement or normalization of cerebral circulation time CTT).

RESULTS

We included 16 angioplasty procedures with retrievable stents in 13 patients, in which 33 arterial segments were treated (10 ICA, 15 MCA, and 8 ACA). We observed no complications of the procedure in any patients and no clinical complications in patients who were not intubated. All but one of the patients who had delayed CTT at the beginning of the procedure showed improvements in CTT. The mean improvement in the degree of stenosis was 18%±11.65% in the ICA, 30.67%±18.45% in the MCA, and 28.38%±15.49% in the ACA. No statistically significant associations were observed between endovascular treatment variables and the degree of improvement in stenosis.

CONCLUSION

Angioplasty with a retrievable stent is a safe and efficacious treatment for vasospasm secondary to SAH due to an aneurysm, improving CTT and stenosis.

The Effects of Cerebral Vasospasm on Cerebral Blood Flow and the Effects of Induced Hypertension: A Mathematical Modelling Study

Background

Induced hypertension has been used to promote cerebral blood flow under vasospastic conditions although there is no randomised clinical trial to support its use. We sought to mathematically model the effects of vasospasm on the cerebral blood flow and the effects of induced hypertension.

Methods

The Anatomically Detailed Arterial Network (ADAN) model is employed as the anatomical substrate in which the cerebral blood flow is simulated as part of the simulation of the whole body arterial circulation. The pressure drop across the spastic vessel is modelled by inserting a specific constriction model within the corresponding vessel in the ADAN model. We altered the degree of vasospasm, the length of the vasospastic segment, the location of the vasospasm, the pressure (baseline mean arterial pressure [MAP] 90 mm Hg, hypertension MAP 120 mm Hg, hypotension), and the presence of collateral supply.

Results

Larger decreases in cerebral flow were seen for diffuse spasm and more severe vasospasm. The presence of collateral supply could maintain cerebral blood flow, but only if the vasospasm did not occur distal to the collateral. Induced hypertension caused an increase in blood flow in all scenarios, but did not normalise blood flow even in the presence of moderate vasospasm (30%). Hypertension in the presence of a complete circle of Willis had a marginally greater effect on the blood flow, but did not normalise flow.

Conclusion

Under vasospastic condition, cerebral blood flow varies considerably. Hypertension can raise the blood flow, but it is unable to restore cerebral blood flow to baseline.

Endovascular Treatment of Intracerebral Giant Cell Arteritis

Background: Giant cell arteritis (GCA) is the most common primary systemic vasculitis predominantly affecting large and medium sized vessels. In rare cases, the vasculitis can affect the vessels of the brain. Results: We describe four cases of GCA with involvement of the cerebral vessels causing stroke. These cases were unresponsive to aggressive immunosuppression and we opted to treat with endovascular balloon dilatation of the stenotic areas. The procedure was safe. The four patients were treated in nine sessions and a total of 16 vessels were treated. We observed two dissections with no clinical influence on the patients. Discussion: In patients with stroke due to progressive GCA that is non-responsive to immunosuppression, endovascular therapy is feasible.

Novel Treatment of Cerebral Vasospasm Using Solitaire Stent Retriever-Assisted Angioplasty: Case Series

BACKGROUND

Endovascular procedures such as intraarterial (IA) vasodilator injection and balloon angioplasty are used to treat medically refractory cerebral vasospasm. The effects of IA therapy may be short lived and thus require multiple treatments. Balloon angioplasty also has limitations including transient occlusion of the spastic blood vessel, possible endothelial injury, and limited access to proximal vessels. We aim to demonstrate a novel technique using a stent retriever for the management of medically refractory vasospasm, especially in distal vessels. Compared with balloon angioplasty, stent retrievers provide a passive, self-limiting expansion of blood vessels. Other benefits over balloon angioplasty include 1) ability to simultaneously inject IA vasodilators, 2) limited contact and damage to vessel wall, 3) nonocclusive expansion, and 4) technical ease.

METHODS

Fourteen blood vessels from 6 patients with symptomatic vasospasm after subarachnoid hemorrhage were identified. We injected 5 mg of IA vasodilator medication into the vasospastic segments without radiographic improvement in vessel diameter and blood flow. The stent retriever was deployed for 2-5 minutes in each vasospastic segment.

RESULTS

Distal anterior and posterior circulation segments were easily accessible with the stent retriever system. It resulted in improved vessel diameter and blood flow with subsequent improvement in neurologic examination. All patients demonstrated radiographic resolution of vasospasm. No procedural-related complications were noted.

CONCLUSIONS

We demonstrate the safety and efficacy of a novel technique for the treatment of medically refractory cerebral vasospasm using stent retriever angioplasty in distal vessels. Stent angioplasty can be used as an additional tool in the management of subarachnoid hemorrhage-induced cerebral vasospasm.

Evaluation of clinical and anatomical outcome of staged stenting after acute coiling of ruptured intracranial aneurysms

INTRODUCTION

Stent-assisted coiling has widened indications and improved stability of endovascular treatment of intracranial aneurysms. However, stent-assisted coiling is usually not used to treat acutely ruptured intracranial aneurysms to avoid antiplatelet therapy. The objective of this study is to evaluate a strategy of staged endovascular treatment of ruptured intracranial aneurysms including coiling at the acute phase with complementary stenting with or without coiling at the subacute phase.

MATERIAL AND METHODS

Between 2012 and 2017, we retrospectively identified, in our prospectively maintained database, all patients treated for a ruptured intracranial aneurysm based on this staged stenting strategy. Clinical charts and imaging follow-up were analyzed to assess the procedural safety and feasibility as well as clinical and anatomical outcome.

RESULTS

We identified 23 patients with 23 intracranial aneurysms including 15 (65.2%) women with a mean age of 50 years (range 24-69 years). No rebleeding occurred during the mean delay of 24.3 days between initial coiling and stenting. All procedures were successful and additional coiling was performed in 5/23 procedures (21.7%). Clinical status was unchanged in all patients. At follow-up, the modified Rankin scale was graded 0 in 19/23 (82.6%), 1 in 2/23 (8.7%), and 2 in 2/23 (8.7%) patients, respectively. The rate of complete occlusion rose from 30.4% before the stenting procedure to 52.2% immediately after and 72.7% at follow-up.

CONCLUSION

This strategy of early staged stenting in selected patients is safe and improves immediate intracranial aneurysm occlusion and long-term stability in this population at high risk of intracranial aneurysm recurrence with coiling alone.

Use of stent retriever for treatment of iatrogenic intracranial vasospasm

Cerebral vasospasm is a source of morbidity and mortality, not only associated with aneurysmal subarachnoid hemorrhage (SAH) but also with endovascular procedures. Treatment of vasospasm associated with SAH include trans-luminal balloon angioplasty and intra-arterial delivery of vasodilator medications. We present a case report of a patient who underwent a mechanical thrombectomy for stroke and suffered from vasospasm. This severe flow-limiting vasospasm was successfully treated with the Trevo stent device. Although stent retrievers have become more widespread for thrombectomy, vasospasm treatment has not been often described in the literature. Further study is needed to determine if this is a viable technique for treating resistant vasospasm.

The unexplained success of stentplasty vasospasm treatment : Insights using Mechanistic Mathematical Modeling

BACKGROUND

Cerebral vasospasm (CVS) following subarachnoid hemorrhage occurs in up to 70% of patients. Recently, stents have been used to successfully treat CVS. This implies that the force required to expand spastic vessels and resolve vasospasm is lower than previously thought.

OBJECTIVE

We develop a mechanistic model of the spastic arterial wall to provide insight into CVS and predict the forces required to treat it.

MATERIAL AND METHODS

The arterial wall is modelled as a cylindrical membrane using a constrained mixture theory that accounts for the mechanical roles of elastin, collagen and vascular smooth muscle cells (VSMC). We model the pressure diameter curve prior to CVS and predict how it changes following CVS. We propose a stretch-based damage criterion for VSMC and evaluate if several commercially available stents are able to resolve vasospasm.

RESULTS

The model predicts that dilatation of VSMCs beyond a threshold of mechanical failure is sufficient to resolve CVS without damage to the underlying extracellular matrix. Consistent with recent clinical observations, our model predicts that existing stents have the potential to provide sufficient outward force to successfully treat CVS and that success will be dependent on an appropriate match between stent and vessel.

CONCLUSION

Mathematical models of CVS can provide insights into biological mechanisms and explore treatment approaches. Improved understanding of the underlying mechanistic processes governing CVS and its mechanical treatment may assist in the development of dedicated stents.

A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage.

OBJECTIVE

To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era.

METHODS

A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage.

RESULTS

Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy.

CONCLUSIONS

Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.

Stent-Retriever Angioplasty for Recurrent Post-Subarachnoid Hemorrhagic Vasospasm - A Single Center Experience with Long-Term Follow-Up

PURPOSE

We report our experience of using stent-retrievers for recurrent cerebral vasospasm (CVS) secondary to aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We performed a retrospective review of our prospectively maintained institutional database to identify all patients with recurrent CVS and treated with stent-retrievers between April 2011 and May 2017. All patients were initially treated with intra-arterial (IA) vasodilators and were subsequently re-treated with stent-retrievers if they developed recurrent vasospasm. Patients were categorized into two groups, those in which IA vasodilators were given again prior to the stent-retriever deployment (VD-first) and those in which the stent-retriever was deployed first and IA vasodilators were given subsequently (SR-first).

RESULTS

We identified 12 patients (7 females, mean age 54.9 years), 5 in the VD-first and 7 in the SR-first cohorts. Stent-retriever lumen dilatation was attempted in 53 segments (VD-first 14, SR-first 39). Stent-retriever deployment was technically feasible in all cases. Vasodilation occurred in 71.4% (10/14 segments) in the VD-first group and 82.1% (32/39 segments) in SR-first group. Additional treatment was required in 5 segments. There was no recurrent vasospasm in the SR-first group; however, 3 patients (60%) in the VD-first group showed recurrent vasospasm. No angiographical abnormality was found at long-term follow-up (7 patients, mean 29.1 months).

CONCLUSION

The use of stent-retrievers to treat cerebral vasospasm is technically feasible and can cause long-term vasodilatation; however, this effect is maximized if stent-retrievers are used prior to infusion of IA vasodilators.

The use of a stent-retriever to cause mechanical dilatation of a vasospasm secondary to iatrogenic subarachnoid haemorrhage

Objective To report the use of a stent-retriever in the management of vasospasm secondary to craniopharyngioma resection. Postoperative improvement was seen both clinically and on perfusion imaging. Methods A patient was admitted for resection of a large craniopharygioma. On day 6 postoperatively the patient had an acute hemiparesis. A computed tomography angiogram and perfusion scan demonstrated acute right-sided cerebral vasospasm and a perfusion defect in the territory of the middle cerebral artery (MCA). Results A pREset 4 × 20 mm stent-retriever was used to dilate the M1 and proximal M2 segments of the right MCA mechanically. This resulted in immediate dilatation of the spastic segment and improvement in the transit time on the angiogram. There was an improvement in the clinical status post-procedure and a computed tomography perfusion performed 24 hours after the procedure showed symmetrical perfusion. A computed tomography angiogram and magnetic resonance imaging performed 1 week later showed a symmetrical appearance to the MCA and no evidence of restricted diffusion. Conclusion The use of commercially available stent-retrievers can cause mechanical dilatation of vasospastic vessels. The stents do not need to be deployed for a prolonged period nor do they need to be implanted to have a prolonged dilatory effect on the spastic vessels.