Abstract
Background: The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is also unclear.Objective: The present study evaluates the safety and efficacy of endovascular rescue treatment (ERT, continuous intraarterial nimodipine; IAN, transcutaneous balloon angioplasty, TBA).Methods: In this prospective observational study, we assessed periprocedural complications and side effects in context of ERT. We evaluated neurological status, multimodal neuromonitoring (ptiO2, lactate/pyruvate ratio, transcranial doppler), and cranial imaging (CTP, DSA). All parameters were included into multivariate analysis to determine predictors for the need of retreatment.Results: We included 33 consecutive patients with 54 ERT (IAN n = 35; TBA n = 13; TBA + IAN n = 6). We recorded no serious complications and initial improvement in all parameters (neurostatus 72.3% of patients; ptiO2 15.0 ± 11.7 to 25.8 ± 15.5 mmHg, p < 0.0001; lactate/pyruvate ratio 46.3 ± 27.5 to 31.0 ± 9.7, p <0.05; transcranial doppler 139.0 ± 46.3 to 98.9 ± 29.6 cm/s, p < 0.05; CTP 81.6% of patients; DSA 93.1% of patients). Retreatment (n = 16, 48.5%) was independently associated with preinterventional ptiO2 < 5 mmHg (p <0.01) and early (<72 h) discontinuation of IAN treatment (p = 0.08). DCI related cerebral infarction was noted in n = 8 patients (24.2%). At 3 months after discharge, favorable outcome was noted for n = 11 (35.5%) patients.Conclusion: Provided a detailed decision tree, timely ERT can provide a relatively safe and effective treatment option in those highly-selected patients undergoing multimodality monitoring where conservative treatment options are exhausted. Continuous treatment in particular may be suitable to surpass sustained DCI and was associated with a low rate of DCI related infarction and comparably high percentage of good outcome.
Highlights
Devastating outcome after aneurysmal subarachnoid hemorrhage is closely linked to the initial extent of injury but delayed complications may aggravate this cerebral crisis [1]
endovascular rescue treatment (ERT) was started at 8.7 ± 3.5 days after hemorrhage and 3.4 ± 3.3 days after initiation of induced hypertension
Ten delayed cerebral ischemia (DCI) related cerebral infarctions were noted in eight patients (24.2%)
Summary
Devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH) is closely linked to the initial extent of injury but delayed complications may aggravate this cerebral crisis [1]. In light of increased posthemorrhagic energy demand, vasospasm, and other yet unclear mechanisms frequently exacerbate metabolic and oxygenation mismatch potentially leading to cerebral infarction [2]. This accumulation of detrimental mechanisms, for which delayed cerebral ischemia (DCI) stands as an umbrella term, may result in permanent neurological impairment if refractory to treatment [1]. The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is unclear
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