Abstract 48: High Risk of Symptomatic Vasospasm in Unaffected Arteries in Subarachnoid Hemorrhage Patients Receiving Targeted Endovascular Treatment for Focal Symptomatic Vasospasm

Abstract

Background: Targeted treatment (angioplasty and/or vasodilators) limited to symptomatic artery offers effective and sustained clinical benefit in patients with cerebral vasospasm and cerebral ischemia. However, there is controversy whether arteries that are not symptomatic within the same patients should be treated in the same session (global treatment). Objective: To determine the rates of occurrence of symptomatic vasospasm on previously asymptomatic arterial distributions among patients with subarachnoid hemorrhage who underwent targeted endovascular treatment for symptomatic focal vasospasm. Methods: We retrospectively identified all patients with aneurysmal subarachnoid hemorrhage and selected those who had developed focal symptomatic vasospasm and received targeted treatment with either angioplasty with or without intra-arterial (IA) vasodilators or IA vasodilators alone, in two academic institutions from June 2006- April 2010. We ascertained any new occurrence of ischemic symptoms requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the duration of hospitalization. Blinded reviewer quantitatively graded cerebral vasospasm (50%) in all major arteries on the angiogram acquired for each patient at the time of targeted treatment. Results: Out of the total of 127 patients with aneurysmal subarachnoid hemorrhage, 48 patients developed focal symptomatic vasospasm. Of the 48 patients, 43 received endovascular treatment and 5 patients were treated with medical management for mild angiographic changes. Of the 43 who received targeted endovascular treatment for vasospasm, 17 (40 %) were treated with angioplasty with or without IA vasodilators, and 26 (60%) were treated with IA vasodilators alone. In subsequent days, 13 out of the 43 patients (30%) developed vasospasm associated ischemic symptoms in previously asymptomatic vascular distributions requiring treatment with angioplasty and/ or IA vasodilators. Severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment did not predict the new occurrence of ischemic symptoms requiring endovascular treatment. Conclusions: The high risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global treatment during the initial treatment session for symptomatic vasospasm treatment in preventing subsequent occurrence of ischemic symptoms in previously asymptomatic arteries.