Cerebral vasospasm after subarachnoid hemorrhage from severe arteriovenous malformation

Abstract

Dear Editor,We read with great interest the article entitled“Outcomeof severe arteriovenous malformation-related intracranialhemorrhage: the importance of cisternal subarachnoidhemorrhage and early seizures.” by Rahme et al. [4]Theauthors reviewed the records of 16 consecutive patientswho presented with severe arteriovenous malformation(AVM)-related intracranial hemorrhage. They reportedthat three patients, who had subarachnoid hemorrhage(SAH), died from extensive bihemispheric infarction andrefractory intracranial pressure. Statistical analysisrevealed that SAH and early seizures were significantlyassociated with death. We completely agree with theauthors’ findings and wish to provide further comment.Cerebral vasospasm after SAH from AVM has beenreported to occur in 8-31% of patients [1, 3]. We believethat cerebral vasospasms might be one of the attributablefactors for cerebral infarctions in the three patients whodied in the authors’ series. We consider that physiciansneed to be particularly aware of cerebral vasospasm inpatients with massive SAH from AVM, and that thethreshold of digital subtraction angiography, computedtomography angiography, or magnetic resonance angiographyshouldbeloweredforearlydetectionofcerebralvasospasminpatients with SAH from AVM. Additionally, nimodipine,nicardipine, intra-arterial papaverine, or angioplasty may beefficient for preventing or treating cerebral vasospasm afterSAH from AVM [2, 3, 5]. However, treatment of cerebralvasospasm may augment blood flow to an untreated AVMand promote early rebleeding, especially in cases withuntreated intranidal aneurysms [2, 3, 5]. Early AVM resectioncan prevent rebleeding and also enable treatment of cerebralvasospasm. We consider that early AVM resection andawareness of cerebral vasospasm are required in patientswith massive SAH from AVM.