Endovascular Treatment Of Vasospasm Research Articles

P.130 Efficacy of decompressive craniectomy after subarachnoid hemorrhage: a propensity-matched analysis of a South Australian Cerebrovascular Registry

Background: The efficacy of decompressive craniectomy (DC) for patients with intracranial hypertension secondary to aneurysmal subarachnoid haemorrhage (aSAH) remains unclear. Methods: We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained cerebrovascular registry and compared their outcomes with a propensity-matched cohort who did not. Results: A total of 45 aSAH patients underwent DC between 01/09/2011 and 20/07/2020 and were compared with 45 propensity-matched controls. There were no differences in patient age (p=0.48), gender (p=0.53) or the proportion requiring endovascular vasospasm treatment (p=1.00). However, patients in the DC subgroup had a higher mean WFNS grade (3.47±1.53) compared with matched controls (2.8±1.25, p=0.03). Patients treated with DC had a higher rate of inpatient mortality (20.00% vs 0.00%, p=0.0025), unfavourable outcome (mRS≥4) at 1st (42.22% vs 11.11%, p=0.0016) and final (31.11% vs 2.94%, p<0.001) follow-up, and NIS-Subarachnoid Hemorrhage Outcome Measure positivity (40.00% vs 13.33%, p=0.0079). They also had a higher median mRS at 1st [3(2–4) vs 1(1–2), p<0.001], and final [2(1–4 vs 1(1 (0–2), p<0.001] follow-up. Conclusions: Patients treated with DC fared worse at every endpoint, which was disproportionate to the difference in presenting WFNS grade. These data do not support the use of DC following microsurgical clipping of a ruptured aneurysm.

The Benefits and Feasibility of External Lumbar Cerebrospinal Fluid Drainage for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis and Trial Sequential Analysis.

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage is a main cause contributing to poor outcomes. Removal of blood from the subarachnoid may decrease development of cerebral vasospasm. The purpose of this study is to determine the effect of lumbar cerebrospinal fluid (CSF) drainage on cerebral vasospasm and related complications through meta-analysis and trial sequential analysis (TSA). A systematic search of the literature was performed. Case-control studies of the effects of external lumbar drainage in patients with subarachnoid hemorrhage were included. The association between lumbar drain and vasospasm, cerebral infarction, subsequent treatment, and mortality were evaluated. Eleven of 122 articles were included in the meta-analysis. Lumbar CSF drainage reduces occurrence of vasospasm and related complications. In meta-analysis, the pooled odds ratio for symptomatic vasospasm, cerebral infarct, endovascular treatment for vasospasm, and mortality was 0.40 (95% confidence interval [CI], 0.31-0.51; P= 0.00001), 0.47 (95% CI, 0.35-0.62; P < 0.0001), 0.29 (95% CI, 0.18-0.46; P < 0.0001), and 0.41, (95% CI, 0.23-0.74; P= 0.003), respectively, compared with the non-lumbar drainage group. In TSA, the cumulative Z line crossed α-spending boundaries and reached the required sample size in analysis of symptomatic vasospasm and endovascular treatment for vasospasm. Lumbar CSF drainage can decrease symptomatic vasospasm, cerebral infarction, subsequent endovascular treatment, and mortality. Through TSA, the accuracy and reliability of the effect of lumbar CSF drainage-related cerebral vasospasm and endovascular treatment are increased. Further studies of the association between lumbar drain and cerebral infarction and mortality are required to confirm the generalization of the results.

Vasospasm-Related Death after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Case-Control Study.

Background: Vasospasm after the rupture of an intracranial aneurysm is a frequent phenomenon and is the main cause of morbidity and mortality in patients who have survived intracranial hemorrhage and aneurysm treatment. We analyzed the diagnosis and management of patients with aneurysmal subarachnoid hemorrhage who eventually died from ischemic brain damage due to vasospasm. Methods: Between January 2007 and December 2021 (15 years), a total of 1064 patients were diagnosed with an aneurysmal intracranial hemorrhage in a single comprehensive neurovascular center. Vasospasm was diagnosed in 408 patients (38.4%). A total of 187 patients (17.6%) died within 90 days of the aneurysm rupture. In 64 of these 187 patients (33.7%), vasospasm was considered to be the cause of death. In a retrospective analysis, demographic and clinical data for patients without, with non-fatal, and with fatal vasospasm were compared. The patients with fatal vasospasm were categorized into the following subgroups: “no diagnosis and treatment” (Group a), “delayed diagnosis” (Group b), “cardiovascular complications” (Group c), and “vasospasm-treatment complications” (Group d). Results: Among the patients with fatal vasospasm, 31 (48.4%) were assigned to group a, 26 (40.6%) to group b, seven (10.9%) to group c, and none (0%) to group d. Conclusion: The early recognition of severe posthemorrhagic vasospasm is a prerequisite for any treatment and requires routine diagnostic imaging in all unconscious patients. Aggressive endovascular vasospasm treatment may fail to prevent death but is infrequently the cause of a fatal outcome.

Dual intra-arterial vasodilators in the management of post-aneurysmal subarachnoid haemorrhage vasospasm

ObjectiveEndovascular chemical angioplasty has been in practice in patients with symptomatic cerebral vasospasm secondary to aneurysmal subarachnoid haemorrhage in many neurosurgical centres. However, the evidence base is derived from clinical case series and expert consensus. The aim of this retrospective cohort study is to evaluate the immediate and functional outcomes of endovascular intervention in aneurysmal subarachnoid haemorrhage cerebral vasospasm treated with a combination of vasodilators. MethodsA cohort of 25 patients was identified. Each patient underwent surgical clipping, and endovascular treatment for vasospasm. A combination of Verapamil and Nimodipine was intra-arterially administered. Statistical analysis was performed to determine the rate of response. The angiographic response and functional outcome on discharge (modified Rankin score - MRS) were used as markers of outcome. ResultsThe study cohort consisted of 25 patients with a mean age of 50.3 (SD 11.2). A total of 135 therapeutic DSA’s were performed. There was an associated between MRS outcomes and number of vasodilation’s each patient received. For each additional vasodilation episode, the odds of a poor outcome increased by 1.190. An angiographic response was demonstrated in 88% of patients, a clinical response in 27%. A good functional outcome was achieved in 17/25, 71% at discharge. ConclusionThe combination therapy of Intra-arterial nimodipine and verapamil in patients with aneurysmal subarachnoid haemorrhage vasospasm appears to have a synergistic, if not comparable, outcome to from solitary vasodilatory treatment results and potentially promote future studies with prospective designs to measure the outcomes.

Predictors of the development of takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage and outcomes in patients with intra-aortic balloon pumps.

Takotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs. The authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2. TC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040). TC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.

Automated Grading of Cerebral Vasospasm to Standardize Computed Tomography Angiography Examinations After Subarachnoid Hemorrhage.

Background: Computed tomography angiography (CTA) is frequently used with computed tomography perfusion imaging (CTP) to evaluate whether endovascular vasospasm treatment is indicated for subarachnoid hemorrhage patients with delayed cerebral ischemia. However, objective parameters for CTA evaluation are lacking. In this study, we used an automated, investigator-independent, digital method to detect vasospasm, and we evaluated whether the method could predict the need for subsequent endovascular vasospasm treatment.Methods: We retrospectively reviewed the charts and analyzed imaging data for 40 consecutive patients with subarachnoid hemorrhages. The cerebrovascular trees were digitally reconstructed from CTA data, and vessel volume and the length of the arteries of the circle of Willis and their peripheral branches were determined. Receiver operating characteristic curve analysis based on a comparison with digital subtraction angiographies was used to determine volumetric thresholds that indicated severe vasospasm for each vessel segment.Results: The automated threshold-based volumetric evaluation of CTA data was able to detect severe vasospasm with high sensitivity and negative predictive value for predicting cerebral hypoperfusion on CTP, although the specificity and positive predictive value were low. Combining the automated detection of vasospasm on CTA and cerebral hypoperfusion on CTP was superior to CTP or CTA alone in predicting endovascular vasospasm treatment within 24 h after the examination.Conclusions: This digital volumetric analysis of the cerebrovascular tree allowed the objective, investigator-independent detection and quantification of vasospasms. This method could be used to standardize diagnostics and the selection of subarachnoid hemorrhage patients with delayed cerebral ischemia for endovascular diagnostics and possible interventions.

Endovascular treatment of cerebral vasospasm after subarachnoid hemorrhage: More is more.

Delayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts. Data from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed. The final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome. A preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH. This study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.

Volumetric analysis of intracranial vessels: a novel tool for evaluation of cerebral vasospasm.

Together with other diagnostic modalities, computed tomography angiography (CTA) is commonly used to indicate endovascular vasospasm treatment after subarachnoid hemorrhage (SAH), despite the fact that objective, user-independent parameters for evaluation of CTA are lacking. This exploratory study was designed to investigate whether quantification of vasospasm by automated volumetric analysis of the middle cerebral artery M1 segment from CTA data could be used as an objective parameter to indicate endovascular vasospasm treatment. We retrospectively identified SAH patients who underwent transcranial Doppler sonography (TCD), CTA, and CT perfusion (CTP), with or without subsequent endovascular treatment. We determined vessel volume/vessel length of the M1 segments from CTA data and used receiver operating characteristic curve analysis to determine the optimal threshold of vessel volume to predict vasospasm requiring endovascular treatment. In addition, blinded investigators independently analyzed TCD, CTA, and CTP data. Of 45 CTA examinations with corresponding CTP and TCD examinations (24 SAH patients), nine indicated the need for endovascular vasospasm treatment during examination. In our patients, vessel volume < 5.8µL/mm was moderately sensitive but fairly specific to detect vasospasm requiring endovascular treatment (sensitivity, 67%; specificity, 78%; negative predictive value (NPV), 89%; positive predictive value (PPV), 46%). For CTA, CTP, and TCD, we found NPVs of 96%, 92%, and 89%, PPVs of 40%, 35%, and 35%, sensitivities of 89%, 78%, and 67%, and specificities of 67%, 64%, and 69%, respectively. Vessel volumes could provide a new objective parameter for the interpretation of CTA data and could thereby improve multimodal assessment of vasospasm in SAH patients.

Endovascular Treatment for Vasospasm after Aneurysmal Subarachnoid Hemorrhage Based on Data of JR-NET3.

Endovascular treatments for vasospasm after subarachnoid hemorrhage are typically performed for patients who are refractory to recommended medical therapies. We analyzed the current status of endovascular treatments based on the data of Japanese Registry of Neuroendovascular Therapy (JR-NET)3, and evaluated factors related to improvement of imaging findings and neurological condition, and to mechanical hemorrhage complications. We collected data of 1211 treatments performed from 2010 to 2014. Target vessels for treatments were anterior circulation (n = 1079), posterior circulation (n = 91), and both (n = 32); the distribution of vasospasm was the proximal vessel (n = 754) to the Circle of Willis, distal vessel (n = 329), and both (n = 119). Of the treatments, 948 cases (78.3%) were intra-arterial administration of vasodilators and 259 (21.4%) were percutaneous transluminal angioplasty (PTA); 879 cases were the first intervention. The treatment time from onset was within 3 h in 378 (31.2%) cases, between 3 and 6 h in 349 (28.8%) cases, and over 6 h in 245 (20.2%) cases. The statistically significant factors associated with improvement on imaging findings was the first treatment, and treatment within 3 h from onset compared with that after 6 h. Additionally, the first and early treatments after the symptoms were associated with significantly improved neurological condition. All complications of mechanical hemorrhage occurred along with PTA. The findings show that endovascular treatment for vasospasm was effective, especially for cases who suffered from symptomatic vasospasm with a short interval after onset.

Feasibility of Real-Time Angiographic Perfusion Imaging in the Treatment of Cerebral Vasospasm

Background: Objective assessment and quantification of the severity of cerebral vasospasm following aneurysmal subarachnoid hemorrhage is not routinely utilized. We investigated the feasibility of angiographic perfusion imaging derived from digital subtraction angiography (DSA) following endovascular vasospasm treatment procedures. Methodology: Real-time blood flow analysis was performed using parametric color coding on pre- and postintervention DSA. Semiquantitative parenchymal perfusion parameters (arrival time [AT] of contrast, time to peak [TTP] opacification, and mean transit time [MTT] of contrast) were calculated across 3 vascular territories (anterior cerebral artery [ACA], middle cerebral artery [MCA], and lenticulostriate arteries) using standard 2-D angiographic perfusion software. The pre- and postintervention arterial vessel diameters were compared. Results: Twelve endovascular vasospasm treatments in 6 patients were performed. All patients received intra-arterial vasodilator therapy with either nimodipine, milrinone, or both. Following intra-arterial intervention, parenchymal flow analysis showed improvement in TTP and MTT across all vascular territories (p < 0.002) and improvement in AT in the ACA and MCA territories (p < 0.03). Improvement in parenchymal perfusion parameters was associated with improvement in vessel diameters in all territories following treatment (p < 0.05). Conclusion: Real-time parenchymal perfusion imaging during endovascular vasospasm treatment procedures is feasible and provides reliable semiquantitative measurement of angiographic treatment response.

Early Vasospasm after Aneurysmal Subarachnoid Hemorrhage Predicts the Occurrence and Severity of Symptomatic Vasospasm and Delayed Cerebral Ischemia

Background: Cerebral vasospasm usually develops several days after subarachnoid hemorrhage (SAH) and is generally acknowledged as a strong outcome predictor. In contrast, much less is known about the nature and eventual consequences of early angiographic vasospasm (EAVS) seen on admission digital subtraction angiography (DSA). Therefore, we aimed at identifying the risk factors and clinical impact of EAVS after SAH. Methods: Five hundred and thirty-one SAH patients with admission DSA performed within 72 h after the bleeding event were selected from a comprehensive database containing all consecutive SAH patients treated at our institution between January 2005 and December 2012. Predictors of EAVS, as well as associations between EAVS and delayed vasospasm-related complications, and unfavorable outcome (defined as modified Rankin scale >3) were evaluated in univariate and multivariate analyses. Results: EAVS was seen on 60 DSAs (11.3%) and was independently correlated with delayed symptomatic vasospasm requiring intra-arterial spasmolysis (OR 5.24, p < 0.0001), angioplasty (OR 2.56, p = 0.015) and repetitive endovascular treatment (OR 4.71, p < 0.0001). EAVS also increased the risk for multiple versus single territorial infarction on the follow-up CT scan(s) (OR 2.04, p = 0.047) and independently predicted unfavorable outcome (OR 2.93, p = 0.008). The presence of radiographic signs suspicious for fibromuscular dysplasia were independently associated with the occurrence of EAVS (OR 2.98, p = 0.026) and the need for repetitive endovascular vasospasm treatment (OR 3.95, p = 0.019). Conclusions: In view of the strong correlation with delayed symptomatic vasospasm and its ischemic complications, EAVS can be considered an alerting signal for severe symptomatic vasospasm. Therefore, more attention should be paid to the presence of EAVS on admission DSA.

Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage.

Predictors for cerebral infarction, an important cause of poor outcome after aneurysmal subarachnoid hemorrhage (SAH), were examined. This study used data from the Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) cohort, which included 579 patients whose ruptured aneurysms were treated with either clipping or coiling within 12 days of onset. Patient, clinical, radiographic, and treatment variables associated with cerebral infarction were determined. Ruptured aneurysms were clipped in 282 patients and coiled in 297 patients. Cerebral infarction occurred in 162 patients (28.0 %): 101 patients by cerebral vasospasm, 34 patients by clipping, and 33 patients by coiling. Univariate analyses showed that significant factors associated with cerebral infarction development were Fisher computed tomography (CT) group 3 on admission, premature aneurysm rupture during clipping procedure, cerebrospinal fluid drainage, symptomatic vasospasm, endovascular treatment for vasospasm, and shunt-dependent hydrocephalus. Multivariable logistic regression analyses showed that cerebral infarction was significantly associated with Fisher CT group 3 on admission, larger aneurysm dome size, ruptured posterior circulation aneurysms, premature aneurysm rupture during clipping procedure, symptomatic vasospasm, and infection, while endovascular treatment for vasospasm significantly decreased the development of cerebral infarction. The most important potentially treatable factor associated with cerebral infarction was symptomatic vasospasm.

Endovascular treatment of vasospasm related to acute subarachnoid hemorrhage from ruptured aneurysms.

In the first 2 weeks after subarachnoid hemorrhage caused by a ruptured aneurysm, 30-35 % of surviving patients treated with conservative nonoperative therapy experience rebleeding. This is fatal in 60-90 % of cases and leads to significant disability in 17-20 % of cases. A major factor for this poor outcome is thought to be the vasospasm that occurs in up to 38.7 % by the third day, 46.3 % by the ninth day, and eventually in up to 70 % of patients. Endovascular treatment of aneurysms associated with acute subarachnoid hemorrhage has the potential to decrease the occurrence of rebleeding and therefore decrease the high mortality and morbidity associated with this disease. Treatment of vasospasm, if it does occur, has the potential to further improve patient outcomes. We describe the outcomes of 174 of our patients with acute subarachnoid hemorrhage caused by a ruptured aneurysm who were treated with endovascular techniques. Overall, the majority of our patients experienced a good or excellent outcome.

P-014 Improvement in Angiographic Transit Times Post Endovascular Vasospasm Treatment in Patients with Aneurysmal Subarachnoid Haemorrhage

IntroductionImprovement in cerebral perfusion post endovascular treatment of vasospasm in patients with aneurysmal subarachnoid haemorrhage (aSAH) is typically assessed by comparison of major vessel diameters on digital subtraction angiography (DSA)....

脳血管攣縮に対する血管内治療に関する全国調査

脳血管攣縮に対する血管内治療に関する全国調査

Current Status of Endovascular Treatment for Vasospasm following Subarachnoid Hemorrhage: Analysis of JR-NET2

Endovascular treatments are employed for cerebral vasospasm following subarachnoid hemorrhage, which is not responded to the medical treatments. However, the effect or complication of the treatments is not known well. Here, we analyzed the data of Japanese Registry of Neuroendovascular Therapy 2 (JRNET2) and revealed current status of the endovascular treatment for the cerebral vasospasm. JR-NET2 is conducted from January 1, 2007 to December 31, 2009. Information on the clinical status, imaging studies, treatment methods, the results of treatment, and status 30 days later were recorded. Totally 645 treatments for 480 patients (mean age, 59.4 years; 72.7% woman) were included. Factors related to the neurological improvement and treatment related complications were statistically analyzed. Treatments for ruptured cerebral aneurysm were direct surgery for 366 cases and endovascular treatment for 253 cases. The timing of the endovascular treatment for the cerebral vasospasm was within 3 hours in 209 cases, 3–6 hours in 158 cases, and more than 6 hours in 158 cases. Intra-arterial vasodilator was employed for the 495 cases and percutaneous transluminal angioplasty for 140 cases. Neurological improvement was observed in 372 cases and radiological improvement was seen in 623 cases. The treatment related complication occurred in 20 cases (3.1%), including 6 cases of intracranial hemorrhage, 5 cases of cerebral ischemia, a case of puncture site trouble, and 8 cases of others. Statistical analysis showed early treatment was related to the neurological improvement. Current status of endovascular treatment for cerebral vasospasm was revealed. Endovascular treatment was effective for vasospasm especially was performed early.

Angiographic Perfusion Imaging: Real‐Time Assessment of Endovascular Treatment for Cerebral Vasospasm

Cerebral perfusion analysis is useful in the diagnosis and treatment of cerebral vasospasm. A new modality of real-time cerebral perfusion imaging and analysis has been developed using standard 2-dimensional angiography. We report our initial experience with this technique to assess response to therapy during endovascular vasospasm procedures. Colorized angiographic perfusion maps were obtained immediately before and after endovascular vasospasm treatment. Semiquantitative perfusion parameters (cerebral blood flow, cerebral blood volume, mean transit time, and time to peak) were calculated from time-density curves obtained from intraarterial contrast injection. The effects of intraarterial vasospasm therapy were assessed. Eight vascular territories in 4 patients with vasospasm underwent interventional angiography and angiographic perfusion analysis. Pretreatment perfusion maps demonstrated variable perfusion deficits in specific vascular territories. After endovascular treatment in 6 vessels, improvement was seen to varying degrees in both angiographic appearance and perfusion parameters. Clinical improvement and reduction in transcranial Doppler velocity was also observed. Real-time angiographic perfusion imaging is feasible during endovascular procedures for vasospasm. Perfusion analysis may aid in assessment of efficacy of the intervention. Comparison with traditional perfusion imaging is needed to validate this technique.

Predictors of Severity of Cerebral Vasospasm caused by Aneurysmal Subarachnoid Hemorrhage

Cerebral vasospasm is one of the leading causes of poor outcome after aneurysmal subarachnoid hemorrhage. The risk factors for the development of vasospasm have been evaluated in many clinical studies. However, it remains unclear if vasospasm severity can be predicted. The purpose of this study was to determine if different demographic and clinical factors that appear to be predictors of vasospasm can also prognosticate the severity of cerebral vasospasm. We retrospectively analyzed consecutive patients with subarachnoid hemorrhage who underwent endovascular vasospasm treatment in a single center. In order to define predictors of vasospasm severity, we studied the demographic and clinical characteristics of these patients. Vasospasm severity was defined by cerebral angiography, transcranial Doppler ultrasound, and therapeutic response on endovascular treatment. Statistical analyses were performed to determine significant predictors. A total of 70 patients with vasospasm were included. Early onset of mean flow velocities>160 cm/second on transcranial Doppler ultrasound correlated with severity of angiographic vasospasm (P=.0469) and resistance against intra-arterial papaverine (P=.0277). Younger age (<51 years of age) was significantly associated with severity of vasospasm regarding extension on angiography (P=.0422), the need for repetitive endovascular treatment (P=.0084), persistence of transcranial Doppler ultrasound vasospasm after endovascular treatment (P=.0004), and resistance against intra-arterial papaverine (P=.0341). Younger age and early onset of vasospasm on transcranial Doppler ultrasound are important predictors for vasospasm severity. We recommend early and aggressive therapy in this subgroup.

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

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.

A proposed definition of symptomatic vasospasm based on treatment of cerebral vasospasm after subarachnoid hemorrhage in Japan: Consensus 2009, a project of the 25 Spasm Symposium.

Background:There is a lack of unified information on diagnosis and treatment of cerebral vasospasm (CV) after subarachnoid hemorrhage (SAH) among the hospitals in Japan. Thus, the aim of the study was to define the current practice in this area based on a survey by Japanese neurosurgeons.Methods:A survey on diagnosis and treatment of CV was sent to 414 hospitals each of which performs >100 neurosurgeries annually.Results:Responses were received from 240 hospitals (58.0%). Because accurate criteria for diagnosis of symptomatic vasospasm (SVS) were used in only 33.8% of the hospitals, we proposed a clinical definition of SVS that was approved at the 25th Spasm Symposium (Consensus 2009). This definition is simplified as follows: (1) the presence of neurological worsening; (2) no other identifiable cause of neurological worsening; and (3) confirmation of vasospasm by medical examinations. The results also showed that the Fisher CT scale is used differently for patients with ICH or IVH, with 41.3% of cases with ICH/IVH based on SAH that met Fisher criteria classified into Fisher group 1, 2 or 3, and 46.3% classified into Fisher group 4. There were no major differences in prophylactic therapies of CV and therapy for cerebral ischemia among the hospitals. Endovascular treatment for vasospasm was performed in most hospitals (78.7%); however, the criteria differed among the hospitals: (1) angiographic vasospasm and SVS appeared (37.9%), (2) only when aggressive therapy was ineffective (41.4%).Conclusion:We established a clinical definition of SVS based on the results of this survey (Consensus 2009).