Abstract 206: Intraarterial (IA) Therapy of Cerebral Vasospasm: Comparison of Single Agent vs Multiple Agent Infusion

Abstract

Background: Cerebral vasospasm remains a major cause of morbidity and mortality in patients with subarachnoid hemorrhage. Vasospasm treatment typically includes IA infusion of vasodilators; however the optimal agent/s have not been elucidated. National surveys suggest that IA treatment algorithms vary between centers and commonly involve use of a single agent. We hypothesize that IA infusion of a cocktail of multiple vasodilators is more efficacious than single agent treatment. Methods: A prospective case series of consecutive patients with cerebral vasospasm (Group 2, N=50 patients, 106 vessels) treated between 2010-13 with IA infusion of a specific cocktail of multiple agents (nitroglycerin, verapamil and nicardipine) at a tertiary center, were compared to a historic control group (Group 1, N=54 patients, 116 vessels) at the same center between 2008-10 treated with a single agent (nicardipine or verapamil). Patient demographics, age, and modified Rankin score (mRS) at discharge and 3 months were collected in the cerebrovascular database. Arterial luminal diameters were measured on cerebral angiograms both pre-infusion (PrID) and post-infusion (PoID). The Improvement Ratio (IR) = (PoID - PrID/PrID) x 100 was calculated and statistically compared between groups using the T test. Results: Group 2 demonstrated statistically significant improvement IR 45.8% (SD 36.6) than Group 1 IR 10.9% (SD 12.0), P<0.001. Multiple agent infusion resulted in an average of 34.9% greater vessel diameter improvement than single agent therapy. Comparison of IR between different single agents within group 1 (nicardipine and verapamil) demonstrated no difference in vessel diameter change. Age of the patient had no effect on efficacy in either group. Patient outcomes measured by mRS were similar at discharge and at 3 months follow-up. Discussion: Treatment of cerebral vasospasm with an IA cocktail of nitroglycerine, verapamil, and nicardipine provides significantly better angiographic improvement of vasospasm than single agent therapy. This effect appears independent of patient age. Outcomes measured by mRS at discharge and 3 months were not significantly different, however will be examined in an ongoing prospective multi-center trial.