Treatment of intracranial vasospasm following subarachnoid hemorrhage

Abstract

Vasospasm has been a long known source of delayed morbidity and mortality in aneurysmal subarachnoid hemorrhage patients. Delayed ischemic neurologic deficits associated with vasospasm may account for as high as 50% of the deaths in patients who survive the initial period after aneurysm rupture and its treatment. The diagnosis and treatment of vasospasm has still been met with some controversy. It is clear that subarachnoid hemorrhage is best cared for in tertiary care centers with modern resources and access to cerebral angiography. Ultimately, a high degree of suspicion for vasospasm must be kept during ICU care, and any signs or symptoms must be investigated and treated immediately to avoid permanent stroke and neurologic deficit. Treatment for vasospasm can occur through both ICU intervention and endovascular administration of intra-arterial vasodilators and balloon angioplasty. The best outcomes are often attained when these methods are used in conjunction. The following article reviews the literature on cerebral vasospasm and its treatment and provides the authors' approach to treatment of these patients.

Keywords: balloon angioplasty; cerebral aneurysm; cerebral vasospasm; delayed ischemic neurologic deficit; subarachnoid hemorrhage.

Figure 1

A-P angiographic images of a 58-year old woman with Hunt and Hess grade V subarachnoid hemorrhage from ruptured dissecting right vertebral aneurysm. Concern for vasospasm was generated from routine transcranial Doppler testing. The patient was already maximally medically managed so was taken for angiography. A-P images of RICA (A), LICA (B), and basilar artery (C) showing very severe vasospasm. A-P images of RICA (D), LICA (E), and basilar artery (F) immediately after balloon angioplasty and administration of intra-arterial verapamil showing resolution of the spasm in the ICA, M1, A1, and basilar artery, as well as improvement in the more distal spasm. A-P images of the RICA (G), LICA (H), and basilar artery (I), 6 days after original treatment showing durability of the angioplasty treatment in the ICA, A1, M1, and basilar artery, but recurrence of spasm in the more distal vessels. This was treated with administration of verapamil.