Real-time changes in brain tissue oxygen during endovascular treatment of cerebral vasospasm

Use of the Cascade expandable net to treat cerebral vasospasm - initial clinical experience from a single centre with in vitro benchside tests

Background

The use of self-expanding stents to treat post-hemorrhagic cerebral vasospasm was recently described. We sought to determine the clinical efficacy of the Cascade device to treat delayed cerebral vasospasm (DCV). We performed benchside tests to determine the chronic outward force exerted by the Cascade in comparison to the Solitaire.

Methods

The chronic outward force (COF) of the Cascade M agile and Cascade L Agile was tested with equivalent tests of the Solitaire 4x20mm. Further tests to determine the forces generated in pre-formed tubes of 1.5–6 mm were performed using both fully and partially unsheathed Cascades.

A retrospective review to identify all patients with aSAH and DCV treated with a Cascade device between January 2020 and July 2021. We recorded the treatment arterial vessel diameters and hemorrhagic or ischemic complications.

Results

In vitro the Cascade generated greater radial force than the Solitaire. The force generated by the Cascade M Agile at 1.5 mm was approximately 64% higher than the Solitaire 6x40mm and approximately 350% higher than the Solitaire 4x20mm.

4 patients with DCV were identified all of whom were treated with a cascade device. In all cases there was a significant improvement in the diameter of the vasospastic vessels treated with an average diameter increase of approximately 300%. There were no complications from the Cascade. Delayed CT angiography showed persistent dilatation of the segments treated with the Cascade at 24 h.

Conclusion

The Cascade is a safe and effective device when used to treat DCV secondary to aSAH. Larger studies are required to validate our initial results.

Use of stent retriever for treatment of iatrogenic intracranial vasospasm

Cerebral vasospasm is a source of morbidity and mortality, not only associated with aneurysmal subarachnoid hemorrhage (SAH) but also with endovascular procedures. Treatment of vasospasm associated with SAH include trans-luminal balloon angioplasty and intra-arterial delivery of vasodilator medications. We present a case report of a patient who underwent a mechanical thrombectomy for stroke and suffered from vasospasm. This severe flow-limiting vasospasm was successfully treated with the Trevo stent device. Although stent retrievers have become more widespread for thrombectomy, vasospasm treatment has not been often described in the literature. Further study is needed to determine if this is a viable technique for treating resistant vasospasm.

Stent-Retriever Angioplasty for Recurrent Post-Subarachnoid Hemorrhagic Vasospasm - A Single Center Experience with Long-Term Follow-Up

PURPOSE

We report our experience of using stent-retrievers for recurrent cerebral vasospasm (CVS) secondary to aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

We performed a retrospective review of our prospectively maintained institutional database to identify all patients with recurrent CVS and treated with stent-retrievers between April 2011 and May 2017. All patients were initially treated with intra-arterial (IA) vasodilators and were subsequently re-treated with stent-retrievers if they developed recurrent vasospasm. Patients were categorized into two groups, those in which IA vasodilators were given again prior to the stent-retriever deployment (VD-first) and those in which the stent-retriever was deployed first and IA vasodilators were given subsequently (SR-first).

RESULTS

We identified 12 patients (7 females, mean age 54.9 years), 5 in the VD-first and 7 in the SR-first cohorts. Stent-retriever lumen dilatation was attempted in 53 segments (VD-first 14, SR-first 39). Stent-retriever deployment was technically feasible in all cases. Vasodilation occurred in 71.4% (10/14 segments) in the VD-first group and 82.1% (32/39 segments) in SR-first group. Additional treatment was required in 5 segments. There was no recurrent vasospasm in the SR-first group; however, 3 patients (60%) in the VD-first group showed recurrent vasospasm. No angiographical abnormality was found at long-term follow-up (7 patients, mean 29.1 months).

CONCLUSION

The use of stent-retrievers to treat cerebral vasospasm is technically feasible and can cause long-term vasodilatation; however, this effect is maximized if stent-retrievers are used prior to infusion of IA vasodilators.