Treatment Of Vasospasm Research Articles

Sex differences in patients with ischemia and no obstructive coronary disease subjected to intracoronary acetylcholine test in a multicenter registry

Abstract Background Ischemia with no obstructive coronary disease (INOCA) is increasingly diagnosed because of wide performance of coronary angiography. Prevalence of INOCA is higher in women than in men, however the exact pathophysiological mechanisms which may explain this phenomenon are still not very well understood. Objective To evaluate differences in clinical and procedural characteristics between men and women with INOCA subjected to intracoronary acetylcholine test (Ach). Methods A total of 210 women and 148 men with INOCA diagnosed with coronary angiography, were prospectively enrolled in a multicenter, observational registry. Ach test was performed according to clinical indications in all included patients. After 1-year patients were re-evaluated for major cardiovascular events, angina symptoms and prescribed medical treatment. Results Mean age of 60.6±13.6 years old was similar in both populations, but differences were observed in the prevalence of risk factors: active smoking was more frequent among men (43% vs. 17%, p<0.001), who had also a higher number of associated risk factors (≥3 risk factors were present in 31.2% of men vs. 20.2% of women, p<0.01) and more frequent history of percutaneous coronary revascularization (14.2% vs. 6.7%, p=0.03). Women were more prone to have dyspnea than men (35.5% vs. 20.8%, p=0.01). Men had more coronary atherosclerosis in angiography (57.9% vs. 43.7%, p=0.01) and more slow flow in the left anterior descending artery (21.6% vs. 9.0%, p=0.001). Ach was positive in 36.5% of patients, similar in both sexes, with no differences in the type of induced coronary spasm. Among those with a positive Ach test, at one-year, 36% of women vs. 43.6% of men were on optimal medical treatment for vasospasm although the difference was not statistically significant. Importantly, 41.5% of women and 38.1% of men experienced severe symptoms of angina during follow-up. Conclusions Although men with INOCA have a higher risk profile than women and more coronary atherosclerosis, one third of patients present endothelial dysfunction, similar in both groups, indicating that probably other pathophysiological mechanisms are responsible for it in females. Treatment in these patients remains suboptimal and associated with highly impaired quality of life. Funding Acknowledgement Type of funding source: None

The Impact of Intra-Arterial Papaverine-Hydrochloride on Cerebral Metabolism and Oxygenation for Treatment of Delayed-Onset Post-Subarachnoid Hemorrhage Vasospasm

Delayed posthemorrhagic vasospasm remains among the major complications after aneurysmal subarachnoid hemorrhage (SAH) and can result in devastating ischemic strokes. As rescue therapy, neurointerventional procedures are used for selective vasodilatation. To investigate the effects of intra-arterial papaverine-hydrochloride on cerebral metabolism and oxygenation. A total of 10 consecutive patients, suffering from severe aneurysmal SAH were prospectively included. Patients were under continuous multimodality neuromonitoring and required intra-arterial papaverine-hydrochloride for vasospasm unresponsive to hypertensive therapy. Cerebral metabolism (microdialysis), brain tissue oxygen tension (ptiO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were analyzed for a period of 12 h following intervention. A median dose of 125 mg papaverine-hydrochloride was administered ipsilateral to the multimodality probe. Angiographic improvement of cerebral vasospasm was observed in 80% of patients. During intervention, a significant elevation of ICP (13.7±5.2 mmHg) and the lactate-pyruvate ratio (LPR) (54.2±15.5) was observed, whereas a decrease in cerebral glucose (0.9±0.5 mmol/L) occurred. Within an hour, an increase of cerebral lactate (5.0±2.0 mmol/L) and glycerol (104.4±89.8 μmol/L) as well as a decrease of glucose (0.9±0.4 mmol/L) were measured. In 2 to 5 h after treatment, the LPR significantly decreased (pretreatment: 39.3±15.3, to lowest 30.5±6.7). Cerebral pyruvate levels increased in 1 to 10 h (pretreatment: 100.1± 33.1 μmol/L, to highest 141.4±33.7 μmol/L) after intervention. No significant changes in ptiO2 or CPP occurred. The initial detrimental effects of the endovascular procedure itself were outweighed by an improved cerebral metabolism within 10 h thereafter. As the effect was very limited, repeated interventions or continuous application should be considered.

Subarachnoid hemorrhage. Modern view on intensive therapy

The objective : to analyze the latest data on the management of patients with subarachnoid hemorrhage (SAH). Results : nimodipine is the only drug that possesses evidence-based efficacy to prevent and treat vasospasm. However, there are cases of refractory vasospasm. Furthermore, there are cases of delayed cerebral ischemia without angiographically detected vasospasm. This article describes the diagnostic, classification of the severity of SAH, the dependence of outcomes on the timing of surgical interventions and intensive care (volemia, glycemia, sodium, hemoglobin level, and optimal values of systolic blood pressure), the results of research on the use of drugs and methods potentially effective for the prevention and treatment of cerebral vasospasm.

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.

Effects of nimodipine combined with betahistine on CRP and other inflammatory cytokines and vascular endothelial function in patients with hypertensive cerebral vasospasm.

This study aims to investigate the effect of nimodipine combined with betahistine on the levels of CRP and other inflammatory cytokines, as well as vascular endothelial function in patients with hypertensive cerebral vasospasm. A total of 80 patients with hypertensive cerebral vasospasm from March 2016 to September 2018 were enrolled and randomly equally divided into two groups. At 1 week before enrollment, the application of all antihypertensive drugs was stopped. Then amlodipine tablets were used in control group, based on which nimodipine tablets were applied in observation group. All the patients included were followed up for 1 month. The changes in the cerebral vasospasm index in the course of treatment as well as inflammatory cytokines and indicators related to vascular endothelial function at 1 month after treatment were measured and compared between the two groups. The correlations of the cerebral vasospasm index with the changes in inflammatory cytokines and vascular endothelial function-related factors in the body were analyzed. Finally, the effective rates of blood pressure regulation and cerebral vasospasm treatment were compared, while the adverse reactions and the overall clinical treatment effect of the two groups were evaluated. The cerebral vasospasm indexes in observation group were significantly lower than those in control group at 3 d, 1 week and 1 month after treatment (p < 0.05). At 1 month after treatment, the levels of inflammatory cytokines such as high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) in observation group were significantly reduced compared to those in control group (p < 0.05). As for vascular endothelial function-related indicators, the endothelin-1 (ET-1) level in observation group was markedly lower than that in control group, whereas the level of nitric oxide (NO) was statistically higher than that in control group (p < 0.05). The cerebral vasospasm index was statistically positively correlated with changes in hs-CRP, IL-6, TNF-α and ET-1 (p < 0.05), but negatively correlated with changes in NO (p < 0.05). Besides, the effective rates of blood pressure regulation and cerebral vasospasm treatment in observation group were significantly higher than those in control group (p < 0.05). The overall treatment effective rate in observation group was markedly higher than that in control group (p < 0.05), and there were no significant differences of adverse reactions between the two groups (p > 0.05). For the treatment of hypertensive cerebral vasospasm, combined application of betahistine on the basis of nimodipine can effectively reduce the body's aseptic inflammatory responses, improve vascular endothelial function and increase the cerebral circulation blood flow, which offers a favorable strategy for clinical therapy.

Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device

Delayed cerebral ischemia due to vasospasm following subarachnoid hemorrhage continues to have high morbidity and mortality despite current treatments. This report highlights the use of the Comaneci (Rapid Medical, Yokneam, Israel), a device FDA approved for temporary coil embolization assistance, for the treatment of symptomatic vasospasm. Ten days post subarachnoid hemorrhage, a patient developed acute left-sided hemiparesis with angiographic vasospasm. Through a Headway 17 microcatheter, a Comaneci 17 was deployed in the right ICA terminus, M1, M2, A1, and, A2 segments resulting in improvement of angiographic vasospasm and the patient's left-sided hemiparesis. On the following day, a repeat angiogram demonstrated no recurrence of vasospasm. The patient had complete return on neurologic function by post bleed day 18 continuing to her four-week follow-up appointment. This case demonstrates the feasibility of the Comaneci device as an effective tool in the treatment of vasospasm following subarachnoid hemorrhage.

Posterior Reversible Encephalopathy Syndrome Caused by Induced Hypertension to Treat Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage

The aim of the present study was to describe the case of a patient who had presented to a university hospital with induced-hypertension (IH) posterior reversible encephalopathy syndrome (PRES). We also reviewed all other reports of such patients. We have described the clinical course of a patient who had presented to the university hospital neurosurgical department. We also performed a systematic review of studies related to the incidence of PRES caused by the use of IH in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. The patient had presented with an acute-onset headache and found to have a subarachnoid hemorrhage due to anterior communicating artery aneurysm rupture. She underwent coiling the next day. During the subsequent days, she demonstrated fluctuating clinical examination findings, aphasia, and decreased levels of arousal. Digital subtraction angiography was performed, and the findings were concerning for mild vasospasm of the anterior and middle cerebral arteries. The systolic blood pressure goal was increased to 180-220 mm Hg for an IH trial, which had initially resulted in some transient clinical improvements in her level of arousal. However, the improvement was not sustained. During the next 36 hours, the patient worsened, and she developed left middle cerebral artery syndrome. Given the concern for a possible ischemic event, magnetic resonance imaging was performed, which demonstrated interval development of multiple areas of cortical-based fluid-attenuated inversion recovery hyperintensity consistent with PRES. The systolic blood pressure goal was relaxed to normotension, and ~48 hours later, the patient's clinical status had significantly improved. IH-PRES is a rare complication that should be remembered in the differential diagnosis for at-risk patients.

Endovascular and Surgical Treatment Is Predictive of Readmission Risk After Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a debilitating disease process accounting for 5% of strokes. Although improvements in care have reduced the case-fatality rates, patients have an increased risk of neurological and medical complications after discharge. Additionally, the readmission rates have been increasingly used as a metric for patient care quality. In the present study, we reviewed the medical records of 206 patients who had been treated for aSAH at the University of Virginia from 2011 to 2018 to identify the causes and predictors of readmission. The all-cause readmission rate was 9.8%, 15.3%, and 21.3% within 30, 60, and 180 days, respectively. The readmission rate for neurologic causes was 7.7%, 12.6%, and 18.0% within 30, 60, and 180 days, respectively. The neurologic causes of readmission included aneurysm retreatment, cranioplasty, a fall, hydrocephalus, stroke symptoms, and syncope. Surgical treatment (odds ratio [OR], 4.11-6.30) and endovascular treatment (OR, 3.79-8.33) of vasospasm were associated with an increased risk of all-cause readmission. Endovascular aneurysm treatment (OR, 0.22) was associated with a decreased risk of all-cause readmission. The average interval to the first follow-up appointment at our institution was 55.3 ± 63.3 days. Of the patients who had been readmitted from the emergency room, 65% had not had follow-up contact with physicians at our institution until their readmission. To the best of our knowledge, the present study is the first to have examined the readmission rates for subarachnoid hemorrhage >90 days after treatment. Our results have suggested that the readmission rates >90 days after treatment could still be predicted by the hospital and treatment course during admission and that follow-up appointments with patients earlier in the clinic could identify those patients with a greater risk of readmission.

Left Forefoot Pain And Discoloration- Runner

HISTORY: A 24-year-old female recreational runner with a past medical history of ADHD on Vyvanse presented to clinic for worsening left forefoot pain and great-toe numbness without antecedent trauma. She also noted blue color changes to the great toe. She presented on crutches due to an inability to bear weight on the forefoot. PHYSICAL EXAMINATION: On inspection of the ankle and foot, there was a bluish-hue to the great toe; no swelling was evident in the foot. She was most tender over the plantar second and third metatarsal heads. Range of motion and strength were preserved. PT pulses were symmetric bilaterally, DP pulses were difficult to appreciate. The foot was cool to the touch with hyperalgesia. DIFFERENTIAL DIAGNOSIS: 1. Vasospastic disease2. Arterial embolization 3. Chronic regional pain syndrome TEST AND RESULTS: Left foot AP, lateral, and oblique radiographs: --Normal. Vascular physiological ABI with maneuvers, arterial ultrasound of the bilateral legs:--No arterial disease noted except for flat toe waveforms in toes of BOTH feet. Left great toe is worse. However, pulsality returns with toe warming implying vasospastic component. Plantar flexion and dorsiflexion did not change popliteal flow velocity. Normal ABIs. No evidence of popliteal artery disease. Left foot MRI without contrast:--Inflammatory changes in the soft tissue deep to the second MTP joint. There is an associated ganglion of the plantar plate measuring 4x2mm- although no discrete plantar plate injury is identified, ganglia can be associated with a small tear.ESR: 5. ANA: neg. RF: <15. Centromere B Ab: neg. FINAL WORKING DIAGNOSIS: Digital vasospasm and possible second metatarsal plantar plate injury TREATMENT AND OUTCOMES: From clinic she was immediately referred to vascular surgery, who noted that although the patient’s toe waveforms were dampened in multiple digits she did show improvement with warming. This suggested vasospastic disease, and given Vyvanse’s association with the same, it was discontinued. Her vasculopathic symptoms improved. Due to ongoing metatarsal head discomfort with ambulation, an MRI was obtained to for further evaluation. Results suggested a plantar plate injury, and taping was used to offload the plate. She was eventually transitioned out of the boot and into a carbon plate insole with eventual return to running.

Angioplasty with the scepter C dual lumen balloon catheter and postprocedural result evaluation in patients with subarachnoid hemorrhage related vasospasms

BackgroundDelayed cerebral ischemia is one of the leading causes of death and disability in patients with subarachnoid hemorrhage (SAH). Transluminal balloon angioplasty (TBA) is a therapeutic option for vasospasms affecting proximal intracranial arteries.MethodsAim of this study was to report our experience using the Scepter C balloon catheter in the treatment of cerebral vasospasms due to SAH and evaluate the postprocedural result with the iFlow tool. We reviewed cases of patients treated at our hospital from 2014 to 2018. Patients were screened with transcranial doppler sonography (TCD) and multimodal computed tomography. In case of significant vasospasms, patients were transferred to the angiography suite and treated. We used the iFlow tool to quantify and evaluate the angiographic results by measuring and comparing peak density values on angiograms before and after the mechanical dilation.ResultsThe use of the Scepter C balloon catheter was feasible in all cases. Vasospasms of the anterior cerebral artery were treated in ten cases. We didn’t observe complications or vasospasm recurrences of the treated arteries. The temporal difference between distal vessels and the proximal reference vessel was significantly reduced from a mean of 53%, prior to dilatation, to 26% after the treatment. The difference between pre-dilatation and post-dilatation values was statistically significant for the anterior circulation at the proximal as well as at the distal vessels.ConclusionsWe successfully treated endovascularly patients suffering from cerebral vasospasms refractory to medical treatment using the Scepter C balloon catheter. We didn’t observe any complications. The therapeutic effect could be easily and reliably assessed with the iFlow tool.

Efficacy of intra-arterial nimodipine therapy in the treatment of vasospasm after subarachnoid hemorrhage

Background: This study aims to investigate the efficacy of intra-arterial nimodipine therapy in treating patients that presented with spontaneous subarachnoid hemorrhage and developed vasospasm following aneurysm surgery. Methods: The study includes 37 patients that underwent intra-arterial nimodipine therapy for the treatment of cerebral vasospasm between October 2015 and December 2019. In patients that developed vasospasm, a catheter was selectively inserted into the internal carotid artery, 1–2 mg of nimodipine was diluted with 50 ccs of saline, and was slowly infused through the catheter. Results: In our study, we found the success rate of intra-arterial nimodipine administration to be 78.4% (neurologic findings completely improved in 29 cases). The clinical condition did not improve in 13.5% of cases and worsened in 8.1%. 86.4% of our patients were discharged with good outcomes (mRS score 0–1). Conclusion: We conclude that intra-arterial nimodipine therapy is a cost-effective, safe, and successful method for the treatment of cerebral vasospasm, a condition that directly affects morbidity and mortality after subarachnoid hemorrhage. Prospective studies are needed to determine standard doses and application times in order to establish the efficacy of intra-arterial nimodipine therapy in treating cerebral vasospasm.

Thick and diffuse cisternal clot independently predicts vasospasm-related morbidity and poor outcome after aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with significant morbidity and mortality. The presence of thick, diffuse subarachnoid blood may portend a worse clinical course and outcome, independently of other known prognostic factors such as age, aneurysm size, and initial clinical grade. In this post hoc analysis, patients with aSAH undergoing surgical clipping (n = 383) or endovascular coiling (n = 189) were pooled from the placebo arms of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS)-2 and CONSCIOUS-3 randomized, double-blind, placebo-controlled phase 3 studies, respectively. Patients without and with thick, diffuse SAH (≥ 4 mm thick and involving ≥ 3 basal cisterns) on admission CT scans were compared. Clot size was centrally adjudicated. All-cause mortality and vasospasm-related morbidity at 6 weeks and Glasgow Outcome Scale-Extended (GOSE) scores at 12 weeks after aSAH were assessed. The effect of the thick and diffuse cisternal aSAH on vasospasm-related morbidity and mortality, and on poor clinical outcome at 12 weeks, was evaluated using logistic regression models. Overall, 294 patients (51.4%) had thick and diffuse aSAH. Compared to patients with less hemorrhage burden, these patients were older (median age 55 vs 50 years) and more often had World Federation of Neurosurgical Societies (WFNS) grade III-V SAH at admission (24.1% vs 16.5%). At 6 weeks, all-cause mortality and vasospasm-related morbidity occurred in 36.1% (95% CI 30.6%-41.8%) of patients with thick, diffuse SAH and in 14.7% (95% CI 10.8%-19.5%) of those without thick, diffuse SAH. Individual event rates were 7.5% versus 2.5% for all-cause death, 19.4% versus 6.8% for new cerebral infarct, 28.2% versus 9.4% for delayed ischemic neurological deficit, and 24.8% versus 10.8% for rescue therapy due to cerebral vasospasm, respectively. Poor clinical outcome (GOSE score ≥ 4) was observed in 32.7% (95% CI 27.3%-38.3%) and 16.2% (95% CI 12.1%-21.1%) of patients with and without thick, diffuse SAH, respectively. In a large, centrally adjudicated population of patients with aSAH, WFNS grade at admission and thick, diffuse SAH independently predicted vasospasm-related morbidity and poor 12-week clinical outcome. Patients with thick, diffuse cisternal SAH may be an important cohort to target in future clinical trials of treatment for vasospasm.

Management of Aneurysmal Subarachnoid Hemorrhage: Variation in Clinical Practice and Unmet Need for Follow-up among Survivors–A Single-Center Perspective

The purpose of the present study is to investigate the existence and/or prevalence of clinical practice variation in management of aneurysmal subarachnoid hemorrhage (aSAH) and to determine the need for long-term follow-up. A single-center study was carried out of patients with aSAH over a 5-year period divided into 2 halves (2.5 years each) before and after addition of a dually trained cerebrovascular neurosurgeon. In-hospital clinical practice, clinical outcome (mortality and discharge destination) and long-term outcome (modified Rankin Scale score and Telephone Interview for Cognitive Status [TICS]) were compared using descriptive summaries and nonparametric tests. Among 251 patients admitted with aSAH, 115(45.8%) were before the index event, whereas 136 (54.2%) were during the later period. The aneurysm-securing procedure changed from coil embolization to clip ligation (12/115 [10.4%] vs. 84/136 [61.8%]; P < 0.0001) during the latter years. Interventional treatment for cerebral vasospasm has decreased (58/115 [50.4%] vs. 49/136 [36.0%]; P= 0.0002). Patients surviving hospitalization had more clinic follow-up after discharge during the latter period (42/85 [49.4%] vs. 76/105 [72.4%]; P= 0.0012) and ventriculoperitoneal shunt placement for delayed hydrocephalus (1/85 [1.2%] vs. 9/105 [8.6%]; P= 0.02). A subcohort of aSAH survivors (n= 46) had lower median TICS score during the earlier study period (31.5[interquartile range, 22-36] vs. 33 [interquartile range, 27-38]; P= 0.038). Similarly, preictal smoking status and hyperlipidemia were associated with adverse TICS score in a multivariate model (P= 0.007). Postdischarge clinical follow-up has improved facilitating recognition and treatment of delayed hydrocephalus. Existence of cognitive deficits among survivors calls for establishment of multidisciplinary clinics for long-term management of aSAH.

CT perfusion-guided endovascular treatment of symptomatic cerebral vasospasm in a patient with perimesencephalic non-aneurysmal subarachnoid hemorrhage

Symptomatic vasospasm represents an uncommon complication of perimesencephalic nonaneurysmal subarachnoid hemorrhage (SAH) which is a benign form of SAH without any recognizable source of bleeding accounting for about 15% of non-traumatic SAH [1,2].

The first experience of chemical angioplasty in patients with subarachnoid hemorrhage in the postoperative period

Objective. The study objective is to assess the results of chemical angioplasty results in patients after clipping of ruptured aneurism of cerebral arteries complicated by cerebral vasospasm.Methods: We have examined 18 patients aged from 24 to 66 y.o. with subarachnoid hemorrhage caused by aneurism rupture, who after cerebral vessels clipping received the treatment of cerebral vasospasm by chemical angioplasty with nimodipine.Results: The number of chemical angioplasty sessions ranged from 1 to 9. In three cases, there was a fatal outcome pathogenetically not associated with subarachnoid hemorrhage. Most of discharged patients had no deficit in the level of consciousness; only one patient was transferred to rehabilitation stage with its low level (10 points, Glasgow coma scale). Lindegaard ratio decreased on average from 3.8 to 2.7 after the completion of chemical angioplasty.Conclusions: Chemical angioplasty with nimodipine allows reducing the development rate of significant vasospasm complications after subarachnoid hemorrhage.

Milrinone for refractory cerebral vasospasm with delayed cerebral ischemia.

Intravenous (IV) milrinone is a promising option for the treatment of cerebral vasospasm with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). However, data remain limited on the efficacy of treating cases that are refractory to standard therapy with IV milrinone. The aim of this study was to determine predictors of refractory vasospasm/DCI despite treatment with IV milrinone, and to analyze the outcome of rescue therapy with intraarterial (IA) milrinone and/or mechanical angioplasty. The authors conducted a retrospective cohort study of all patients with aSAH admitted between 2010 and 2016 to the Montreal Neurological Institute and Hospital. Patients were stratified into 3 groups: no DCI, standard therapy, and rescue therapy. The primary outcome was frequency of DCI-related cerebral infarction identified on neuroimaging before hospital discharge. Secondary outcomes included functional outcome reported as modified Rankin Scale (mRS) score, and segment reversal of refractory vasospasm. The cohort included 322 patients: 212 in the no DCI group, 89 in the standard therapy group, and 21 in the rescue therapy group. Approximately half (52%, 168/322) were admitted with poor-grade aSAH at treatment decision (World Federation of Neurosurgical Societies grade III-V). Among patients with DCI and imaging assessing severity of vasospasm, 62% (68/109) had moderate/severe radiological vasospasm on DCI presentation. Nineteen percent (21/110) of patients had refractory vasospasm/DCI and were treated with rescue therapy. Targeted rescue therapy with IA milrinone reversed 32% (29/91) of the refractory vasospastic vessels, and 76% (16/21) of those patients experienced significant improvement in their neurological status within 24 hours of initiating therapy. Moderate/severe radiological vasospasm independently predicted the need for rescue therapy (OR 27, 95% CI 8.01-112). Of patients with neuroimaging before discharge, 40% (112/277) had developed new cerebral infarcts, and only 21% (23/112) of these were vasospasm-related. Overall, 65% (204/314) of patients had a favorable functional outcome (mRS score 0-2) assessed at a median of 4 months (interquartile range 2-8 months) after aSAH, and there was no difference in functional outcome between the 3 groups (p = 0.512). The aggressive use of milrinone was safe and effective based on this retrospective study cohort and is a promising therapy for the treatment of vasospasm/DCI after aSAH.

Overview of patients with vascular pathology and cost analysis of medical care – research market for an entrepreneurial project

Introduction: Brain vascular pathology, aneurysms, arteriovenous malformations (AVMs), cavernomas, dural arteriovenous fistulas (DAVF), venous angiomas and capillary telangiectasia, represents a serious health problem worldwide.&#x0D; Aim: The aim of this article is to perform an analysis of patients with brain vascular pathology and to analyze costs of health services, a research market for an entrepreneurial project, in order to design guidelines for patients’ selection and treatment.&#x0D; Material and methods: We performed an observational, descriptive study of patients with vascular pathology, from 2018 to 2019.&#x0D; Results: A total of 153 patients with brain vascular pathology were admitted in our department. Mean age was 49.53 ± 13.997 years. Sex ratio was 0.86. Mean hospital stay was 11.33 ± 13.724 days. Seventy-four patients (48.37%) underwent surgery. Seventy-eight patients (50.98%) had cerebral aneurysms. Complications were seen in 24 patients (30.77%) and vasospasm in 32 cases (41.03%). Thirty-six patients underwent surgery. Outcome was favorable, according to mRS(p=0.001) and Karnofsky score(p=0.006).Thirty-three patients (21.57%) had brain AVMs. Twenty patients underwent surgery. Complications were seen in 4 cases (12.12%). The outcome was favourable, according to mRS(p=0.001) and Karnofsky score (p=0.002). Thirty-nine patients (25.49%) had cavernomas. Surgery was performed in 18 cases. The outcome was favourable, according to Engel Epilepsy Surgery Outcome Scale, mRS (p=0.000) and Karnofsky score (p =0.000). Costs of health services were correlated with longer hospitalization, higher mRS, lower Karnosfsky score, presence of complications and presence of vasospasm.&#x0D; Conclusions: Proper treatment of brain vascular pathology ensures a favourable outcome. Adequate patients’ selection and choosing the best treatment can reduce costs. Surgery is the treatment of choice in ruptured aneurysms, AVMs and cavernomas. Early surgery, with specific treatment of the vascular lesion and removal of intracranial blood ensures a better outcome, with lower medical costs. Prevention of complications, aggressive treatment of vasospasm reduces medical costs.

Non-steroidal anti-inflammatory drugs in the pathophysiology of vasospasms and delayed cerebral ischemia following subarachnoid hemorrhage: a critical review.

Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening condition associated with the development of early brain injury (EBI) and delayed cerebral ischemia (DCI). Pharmacological treatment of vasospasm following aSAH currently mainly comprises nimodipine administration. In the past few years, many drugs that can potentially benefit cases of subarachnoid hemorrhage have become available. The objective of this review is to critically assess the effects of non-steroidal anti-inflammatory drugs (NSAIDs) following aSAH. A systematic literature review was conducted following PRISMA guidelines. The search was aimed at studies addressing aSAH and NSAIDs during the 2010 to 2019 period, and it yielded 13 articles. Following the application of search criteria, they were divided into two groups, one containing 6 clinical articles and the other containing 7 experimental articles on animal models of aSAH. Inflammatory cerebral changes after aneurysm rupture contribute to the development of EBI, DCI and cerebral vasospasm. It appears that NSAIDs (especially coxibs) are even more effective in reducing vasospasm than nimodipine. Other beneficial effects of NSAIDs include reduction in mortality, improved functional outcome and increased hypoaggregability. However, despite these positive effects, there is only one randomized, double-blind, placebo-controlled trial showing a tendency towards a better outcome with lower incidence of vasospasm or mortality in patients following aSAH.

Continous local Intra –arterial Nimodipine administration in severe symptomatic vasospasm after spontanous subarachnoid hemorrhage:a meta-analysis

Abstract Background Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space (the area between the arachnoid membrane and the pia mater surrounding the brain). SAH is a potentially life threatening condition. Hemorrhage may occur as a result of a head injury or spontaneously (usually from a ruptured cerebral aneurysm). Spontaneous subarachnoid hemorrhage occurs in about one per 10,000 people per year. Females are more commonly affected than males. While it becomes more common with age, about 50% of people present under 55 years old. It is a form of stroke and comprises about 5 % of all strokes. Disturbed conscious level, specially that associated with cerebral arterial vasospasm, remains a major cause of death and disability in the patients with aneurysmal subarachnoid hemorrhage.The classical modality of management for vasospasm was oral calcium channel blockers (nimodipine) with triple-H therapy (Hypedynamic augmentation therapy). Aim To evaluate the effect of Continous local Intra –arterial nimodipine administration in severe symptomatic vasospasm after spontanous subarachnoid hemorrhage on mortality and morbidity (symptomtic cerebral ischemia). Methodology: Studies and participants In the current meta-analysis, we searched for interventional clinical trials in critically ill adult patients that evaluated to have aneurysmal subarachnoid hemorrhage complicated by severe symptomatic vasospasm (causing delayed cerebral ischemia and neurological deficits) which was refractory to standard hyper dynamic therapy (triple- H therapy) and oral calcium channel blockers (CCBS). Results In the current meta-analysis, the duration of infusion of nimodipine was at least for 72 hours. The onset of occurance of cerebral vasodilation after the infusion in all studies by their different doses was 12 hours detected by transcranial doppler. The time of termination of nimodipine infusion is different from patient to other patient depending on clinical improvement ( improvement of consious level or disappearance of the newly developed neurological deficit) and radiological findings that refers to the relief of vasospasm assesed by transcranial doppler and cerebral angiography. Reinfusion of the nimodipine was done in all included studies in case of recurrence of vasospasm causing new neurological deficit or deterioration in the conscious level . Conclusion It concluded from the current meta-analysis that, intra-arterial nimodipine infusion is effective and safe treatment for syptomatic refractory vasospasm after aneurysmal subarachnoid hemorrhage.

Abstract TP463: Treatment of Asymptomatic Angiographic Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage May Prevent Progression to Delayed Cerebral Ischemia

Objective: Endovascular treatment of angiographic cerebral arterial vasospasm (CVS) in patients with aneurysmal subarachnoid hemorrhage (aSAH), who do not fulfill criteria for delayed cerebral ischemia (DCI), remains controversial. We sought to investigate the relationship of endovascular intervention with the development of DCI. Method: Consecutive patients admitted between 2017 and 2019 with aSAH were analyzed retrospectively. Rates of development of DCI were compared between two groups - the treated group: patients not in DCI who underwent conventional digital subtraction angiography (DSA) between days 3 and 14 of ictus and were treated endovascularly for CVS, - the untreated group: patients who did not undergo DSA or did get DSA but did not receive endovascular treatment for CVS. Pearson’s chi-square test for independence was used to compare progression to DCI and t-test for independent samples was used to compare modified fisher scale (mFS) among the 2 groups. Multivariate logistic regression using stepwise backward selection was used to evaluate the predictors of DCI. Results: A total of 83 patients were analyzed. 21 patients (25%) were treated for angiographic vasospasm. 70% of these patients had moderate or severe CVS. 15 (15%) underwent DSA but were not treated angiographically. DSA was performed on an average of day 8 [5-12] post-ictus. 47 (57%) did not received DSA. Although, patients treated for angiographic CVS had higher modified Fisher Scale mFS (p=0.11), the rate of progression to DCI was higher among the untreated group 20 (32%) compared to the treated group (10%) (p =0.04). Delayed cerebral ischemia occurred at an average of day 6 [2-16] post-ictus. Although 15 out of 36 (42%) had DSA but were untreated due to absence or visualization of non-significant CVS, the treated group (68%) had significantly higher mFS (p=0.02) and elevated TCD velocities (p=0.03). mFS (p=0.04) and lack of past medical history of hypertension (p=0.03) were predictors of DCI. Conclusion: Endovascular treatment of angiographic CVS in asymptomatic patients was associated with lower risk of progression to DCI. A large prospective study is needed to evaluate its potential to prevent progression to DCI in high risk patients.