Non-compliant and compliant balloons for endovascular rescue therapy of cerebral vasospasm after spontaneous subarachnoid haemorrhage: experiences of a single-centre institution with radiological follow-up of the treated vessel segments

Neuroradiological diagnosis and therapy of cerebral vasospasm after subarachnoid hemorrhage

BACKGROUND

Cerebral damage after aneurysmal subarachnoid hemorrhage (SAH) results from various, sometimes unrelated causes. After the initial hemorrhage trauma with an increase in intracranial pressure, induced vasoconstriction, but also microcirculatory disturbances, inflammation and pathological electrophysiological processes (cortical spreading depolarization) can occur in the course of the disease, resulting in delayed cerebral ischemia (DCI). In the neuroradiological context, cerebral vasospasm (CVS) remains the focus of diagnostic imaging and endovascular therapy as a frequent component of the genesis of DCI.

METHODS

The amount of blood leaked during aneurysm rupture (which can be detected by CT, for example) correlates with the occurrence and severity of CVS. CT perfusion is then an important component in determining the indication for endovascular spasm therapies (EST). These include intra-arterial drug administration (also as long-term microcatheter treatment) and mechanical procedures (balloon angioplasty, vasodilatation using other instruments such as stent retrievers, stenting).

CONCLUSION

This review summarizes the current findings on the diagnosis and treatment of CVS after aneurysmal SAH from a neuroradiological perspective, taking into account the complex and up-to-date international literature.

KEY POINTS

· Vasospasm is a frequent component of the multifactorial genesis of delayed cerebral ischemia after SAH and remains the focus of diagnosis and treatment in the neuroradiological context.. · The initial extent of SAH on CT is associated with the occurrence and severity of vasospasm.. · CT perfusion is an important component in determining the indication for endovascular spasm therapy.. · Endovascular spasm therapies include local administration of medication (also as long-term therapies with microcatheters) and mechanical procedures (balloon angioplasty, dilatation using other devices such as stent retreivers, stenting)..

CITATION FORMAT

· Neumann A, Schacht H, Schramm P. Neuroradiological diagnosis and therapy of cerebral vasospasm after subarachnoid hemorrhage. Fortschr Röntgenstr 2024; 196: 1125 - 1133.

Treatment of Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage Using the Compliant Manually Adjustable Mesh Comaneci

Background and purpose: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Compliant and noncompliant balloons and manually adjustable mesh may be used in this indication. We describe our initial experience with the Comaneci (Rapid Medical, Yokneam, Israel) in cerebral vasospasm treatment following aSAH. Methods: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Comaneci device for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details, and outcomes were obtained from electronic medical records. Results: Between February 2022 and June 2023, seven consecutive patients underwent CV treatment with the Comaneci. Angioplasty of 37 arterial segments (supraclinoid internal carotid artery, A1, A2, and A3 segments of the anterior cerebral artery and M1 and M2 segments of the middle cerebral artery) was attempted, and 35/37 (95%) were performed. The vessel diameter improved significantly following angioplasty (+64%), while brain hypoperfusion decreased (-45% of the mean T Max). There was no long-term clinical complication, and 6% per-procedural complications occurred. Conclusions: The Comaneci is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device in the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Enteral Cilostazol and High-Dose Intravenous Albumin in Aneurysmal Subarachnoid Hemorrhage Patients With Refractory Cerebral Ischemia

Cerebral ischemia associated with vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH) requires a multifaceted approach. We report the use of the combination of enteral cilostazol and intravenous (IV) high-dose albumin in aSAH patients with cerebral ischemia refractory to other accepted pharmacologic and endovascular treatments. Three aSAH patients who developed cerebral ischemic symptoms despite treatment with oral nimodipine and endovascular measures (i.e., intraarterial vasodilators and balloon angioplasty) were treated with enteral cilostazol (200 mg/day) and one or more doses of IV (25%) albumin (1.25 g per kg over eight hours). The patients were monitored by serial neurological examinations, transcranial Doppler imaging (TCDI) ultrasound, computed tomographic angiography (CTA), and perfusion (CTP) scans. Three patients (ages 58, 67, and 56 years) developed symptomatic cerebral ischemia and vasospasm following an aSAH. Due to limited angiographic response to endovascular treatment, including intraarterial vasodilators with or without balloon angioplasty, IV (25%) albumin and enteral cilostazol were administered. CT angiogram and perfusion 2-3 days post-treatment demonstrated resolution of the perfusion deficits and angiographic vasospasm. Concurrently, TCDI demonstrated improved vasospasm and clinical examination demonstrated resolution of neurological deficits. None of the patients required any additional treatments for cerebral ischemia. A combination of oral cilostazol and IV high dose (25%) albumin was associated with amelioration of angiographic vasospasm, reduction of tissue perfusion deficits, and clinical improvement of aSAH patients with severe refractory cerebral ischemia.

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.

Do Balloon Catheters have a Different Radial Force Along Their Longitudinal Axis?

PURPOSE

This experimental study was designed to compare radial forces between the central portion and both ends of balloon catheters when dilating stenosis.

MATERIALS AND METHODS

Three balloon catheters of 6 and 8 mm in diameter and of variable length were tested: Mustang, Conquest, and Genoss PTA. Cylindrical modules to position balloon catheters and install the measuring tip during radial force measurements were made using a 3D printer. The measuring tip created 20% stenosis at the inner lumen. Both ends and center of the balloon catheter were located at the measuring tip. The radial force was measured after inflating the balloon catheter to the rated burst pressure.

RESULTS

For the different diameters and lengths of balloon catheters and cylinder sizes, the median inccenter, the radial rease in radial force at the distal end compared to the center was 16.5% (range: 9.8-35.2%) for Mustang, 12.4% (range: 10.3-25.5%) for Genoss, and 7.4% (range: -0.3-13.1%) for Conquest balloon catheters. Similarly, compared to that at the force at the proximal end was 10.8% greater (range: -2.9-18.3%) for Mustang, 9.9% greater (range: 3.9-22.3%) for Genoss, and 7.3% greater (range: -1.3-12.4%) for Conquest catheters.

CONCLUSION

The radial force is greater at both ends of the balloon than at the central portion, especially at the distal end. Dilation using the distal end of the balloon catheter is a practical method that can be applied in clinical practice without additional devices when encountering resistant stenosis, especially with semi-compliant balloons.

Diagnosis and endovascular management of vasospasm after aneurysmal subarachnoid hemorrhage - survey of real-life practices

BACKGROUND

Vasospasm and delayed cerebral ischemia (DCI) are the leading causes of morbidity and mortality after intracranial aneurysmal subarachnoid hemorrhage (aSAH). Vasospasm detection, prevention and management, especially endovascular management varies from center to center and lacks standardization. We aimed to evaluate this variability via an international survey of how neurointerventionalists approach vasospasm diagnosis and endovascular management.

METHODS

We designed an anonymous online survey with 100 questions to evaluate practice patterns between December 2021 and September 2022. We contacted endovascular neurosurgeons, neuroradiologists and neurologists via email and via two professional societies - the Society of NeuroInterventional Surgery (SNIS) and the European Society of Minimally Invasive Neurological Therapy (ESMINT). We recorded the physicians' responses to the survey questions.

RESULTS

A total of 201 physicians (25% [50/201] USA and 75% non-USA) completed the survey over 10 months, 42% had >7 years of experience, 92% were male, median age was 40 (IQR 35-46). Both high-volume and low-volume centers were represented. Daily transcranial Doppler was the most common screening method (75%) for vasospasm. In cases of symptomatic vasospasm despite optimal medical management, endovascular treatment was directly considered by 58% of physicians. The most common reason to initiate endovascular treatment was clinical deficits associated with proven vasospasm/DCI in 89%. The choice of endovascular treatment and its efficacy was highly variable. Nimodipine was the most common first-line intra-arterial therapy (40%). Mechanical angioplasty was considered the most effective endovascular treatment by 65% of neurointerventionalists.

CONCLUSION

Our study highlights the considerable heterogeneity among the neurointerventional community regarding vasospasm diagnosis and endovascular management. Randomized trials and guidelines are needed to improve standard of care, determine optimal management approaches and track outcomes.

Treatment of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage using the Neurospeed Semi-compliant Balloon

BACKGROUND AND PURPOSE

Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Off-label compliant remodelling balloons tend to conform to the course of the vessel, contrary to noncompliant or semi-compliant balloons. Our objective is to describe our initial experience with the semi-compliant Neurospeed balloon (approved for intracranial stenosis) in cerebral vasospasm treatment following aSAH.

METHODS

All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Neurospeed balloon for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details and outcomes were obtained from electronic medical records.

RESULTS

Between February 2022 and June 2023, 8 consecutive patients underwent CV treatment with the Neurospeed balloon. Angioplasty of 48 arterial segments (supraclinoid internal carotid artery, A1 and A2 segments of the anterior cerebral artery, M1 and M2 segments of the middle cerebral artery) was attempted and 44/48 (92%) were performed. The vessel diameter significantly improved following angioplasty (+81%), while brain hypoperfusion decreased (-81% of the mean TMax). There was no long-term clinical complication, 4% periprocedural complications occurred.

CONCLUSION

The semi-compliant Neurospeed balloon is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device into the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Continuous Intraarterial Nimodipine Infusion for the Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Retrospective, Single-Center Cohort Trial

Background

Delayed cerebral ischemia (DCI) occurs after aneurysmal subarachnoid hemorrhage (aSAH). Continuous intraarterial nimodipine infusion (CIAN) is a promising approach in patients with intracranial large vessel vasospasm (LVV). The objective of this retrospective single-center cohort study was to evaluate the outcome in aSAH-patients treated with CIAN.

Methods

CIAN was initiated and ended based on the clinical evaluation and transcranial Doppler (TCD), CT-angiography, CT-perfusion (PCT), and digital subtraction angiography (DSA). Nimodipine (0.5–2.0 mg/h) was administered continuously through microcatheters placed in the extracranial internal carotid and/or vertebral artery. Primary outcome measures were Glasgow Outcome Scale (GOS) at discharge and within 1 year after aSAH, and the occurrence of minor and major (<⅓ and >⅓ of LVV-affected territory) DCI-related infarctions in subsequent CT/MRI-scans. Secondary outcome measures were CIAN-associated complications.

Results

A total of 17 patients underwent CIAN. Median onset of CIAN was 9 (3–13) days after aSAH, median duration was 5 (1–13) days. A favorable outcome (GOS 4–5) was achieved in 9 patients (53%) at discharge and in 13 patients within 1 year (76%). One patient died of posthemorrhagic cerebral edema. Minor cerebral infarctions occurred in five and major infarctions in three patients. One patient developed cerebral edema possibly due to CIAN. Normalization of PCT-parameters within 2 days was observed in 9/17 patients. Six patients showed clinical response and thus did not require PCT imaging.

Conclusion

The favorable outcome in 76% of patients after 1 year is in line with previous studies. CIAN thus may be used to treat patients with severe therapy-refractory DCI.