Feasibility and Safety of Repeat Instant Endovascular Interventions in Patients with Refractory Cerebral Vasospasms

Abstract

Background and purpose: For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions.

Materials and methods: This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions.

Results: During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions (P = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; P = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; P = .004).

Conclusions: Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.

Fig 1.

Repeat angiograms in refractory cerebral vasospasms. Repeat angiograms (red arrows: proximal spastic vessels; blue arrows: distal spastic vessels) in a 41-year-old woman with a ruptured anterior communicating artery aneurysm initially treated with coil embolization. On day 8 after the ictus, the patient presented with hemiparesis on the left side. A, ICA angiogram, anteroposterior view, shows vasospasm of the right-sided M1 and A1/A2 segments. B, ICA angiogram of the same patient after nimodipine infusion demonstrates reduced vasospasm of the M1 and A1/A2 segments, with improved perfusion of both the proximal and distal arteries. C–M, Corresponding angiograms of the anterior circulation (C, D, G, H, L, M) and posterior circulation (E, F, I, K) in the same patient during the CVS period from day 9 to day 13. Images on the right side show the effect after IAN. Note the effect of nimodipine infusion on the vessel diameter (white arrows).