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.

MicroRNA‑29a contributes to intracranial aneurysm by regulating the mitochondrial apoptotic pathway

Intracranial aneurysm (IA) is an abnormal expansion in the intracranial arteries that weakens the arterial wall by consistently pushing the vascular wall outwards, which leads to a higher risk of aneurysm rupture. A number of reports have demonstrated that apoptosis is associated with the growth and rupture of IA. MicroRNAs (miRNAs/miRs) perform vital roles in the regulation of the mitochondrial apoptotic pathway and signaling proteins. Increasing evidence has already revealed the role of miR‑29a in injury, including liver injury, cardiovascular injury and ischaemia‑reperfusion injury. However, the role of miR‑29a in IA remains unclear at present. The present study investigated the role of miR‑29a in IA pathogenesis and the underlying mechanisms. By using reverse transcription‑quantitative polymerase chain reaction and western blot analysis, the present study demonstrated that genes, including caspase‑3, ‑8 and ‑9, and proteins, including cytochrome c and myeloid cell leukemia 1 (Mcl‑1), involved in mitochondrial apoptosis pathways were upregulated in IA groups compared with controls. In addition, microarray analysis demonstrated that miR‑29a, one of the most altered miRs in IA mice, was overexpressed in IA mice compared with controls. In vitro experiments revealed that miR‑29a downregulation attenuated human brain vascular smooth muscle cell (HBVSMC) apoptosis, while miR‑29a overexpression increased the apoptosis of HBVSMCs. Furthermore, luciferase reporter analysis revealed that Mcl‑1 is a direct target gene of miR‑29a. An in vivo IA model confirmed that miR‑29a overexpression may promote apoptosis through mitochondrial pathways. It was therefore concluded that miR‑29a may contribute to the progression of IA by regulating mitochondrial apoptotic pathways. Thus, miR‑29a is a potential therapeutic target for IA.

[Treatment of postoperative vasospasm after insular tumor removal by intra-arterial administration of verapamil (analysis of two clinical cases and a literature review)]

PURPOSE

We describe our experience of using intra-arterial administration of Verapamil to resolve vasospasm in two patients who underwent surgery for insular glial tumors.

MATERIAL AND METHODS

Severe vasospasm (an increased systolic LBFV in the M1 MCA, more than 250 cm/s, and a Lindegaard index of 4.1) was observed in 2 (3.2%) of 62 patients in the early postoperative period after removal of intracerebral insular tumors. In both cases, vasospasm was confirmed by angiography, was clinically significant, and manifested by the development of pyramidal hemisyndrome.

RESULTS

Intra-arterial administration of Verapamil led to relief of angiospasm, which was confirmed by angiographic data, and complete regression of neurological symptoms.

CONCLUSION

Vasospasm symptoms in patients after removal of insular tumors largely resemble those after aneurysm hemorrhage. An increase in the LBFV in the MCA and related neurological symptoms develop lately and persists for up to 2 weeks after surgery. LBFV values are similar to those in patients after SAH and reach 250-300 cm/s. Among the causes of focal symptoms developed after removal of insular tumors, injury to the inner capsule structures, injury to arteries of the MCA territory (especially perforators), and angiospasm should be differentiated.

Feasibility and Safety of Repeat Instant Endovascular Interventions in Patients with Refractory Cerebral Vasospasms

BACKGROUND AND PURPOSE

For patients with cerebral vasospasm refractory to medical and hemodynamic therapies, endovascular therapies often remain the last resort. Data from studies in large cohorts on the efficacy and safety of multiple immediate endovascular interventions are sparse. Our aim was to assess the feasibility and safety of multiple repeat instant endovascular interventions in patients with cerebral vasospasm refractory to medical, hemodynamic, and initial endovascular interventions.

MATERIALS AND METHODS

This was a single-center retrospective study of prospectively collected data on patients with cerebral vasospasm refractory to therapies requiring ≥3 endovascular interventions during the course of treatment following aneurysmal subarachnoid hemorrhage. The primary end point was functional outcome at last follow-up (mRS ≤2). The secondary end point was angiographic response to endovascular therapies and the appearance of cerebral infarctions.

RESULTS

During a 4-year period, 365 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Thirty-one (8.5%) met the inclusion criteria. In 52 (14%) patients, ≤2 endovascular interventions were performed as rescue therapy for refractory cerebral vasospasm. At last follow-up, a good outcome was noted in 18 (58%) patients with ≥3 interventions compared with 31 (61%) of those with ≤2 interventions (P = .82). The initial Hunt and Hess score of ≤2 was a significant independent predictor of good outcome (OR, 4.7; 95% CI, 1.2-18.5; P = .03), whereas infarcts in eloquent brain areas were significantly associated with a poor outcome (mRS 3-6; OR, 13.5; 95% CI, 2.3-81.2; P = .004).

CONCLUSIONS

Repeat instant endovascular intervention is an aggressive but feasible last resort treatment strategy with a favorable outcome in two-thirds of patients with refractory cerebral vasospasm and in whom endovascular treatment has already been initiated.

Beta-blocker therapy and impact on outcome after aneurysmal subarachnoid hemorrhage: a cohort study

OBJECTIVE

Cerebral vasospasm (cVSP) is a frequent complication of aneurysmal subarachnoid hemorrhage (aSAH), with a significant impact on outcome. Beta blockers (BBs) may blunt the sympathetic effect and catecholamine surge associated with ruptured cerebral aneurysms and prevent cardiac dysfunction. The purpose of this study was to investigate the association between preadmission BB therapy and cVSP, cardiac dysfunction, and in-hospital mortality following aSAH.

METHODS

This was a retrospective cohort study of patients with aSAH who were treated at a tertiary high-volume neurovascular referral center. The exposure was defined as any preadmission BB therapy. The primary outcome was cVSP assessed by serial transcranial Doppler with any mean flow velocity ≥ 120 cm/sec and/or need for endovascular intervention for medically refractory cVSP. Secondary outcomes were cardiac dysfunction (defined as cardiac troponin-I elevation > 0.05 μg/L, low left ventricular ejection fraction [LVEF] < 40%, or LV wall motion abnormalities [LVWMA]) and in-hospital mortality.

RESULTS

The cohort consisted of 210 patients treated between February 2009 and September 2010 (55% were women), with a mean age of 53.4 ± 13 years and median Hunt and Hess Grade III (interquartile range III–IV). Only 13% (27/210) of patients were exposed to preadmission BB therapy. Compared with these patients, a higher percentage of patients not exposed to preadmission BBs had transcranial Doppler-mean flow velocity ≥ 120 cm/sec (59% vs 22%; p = 0.003). In multivariate analyses, lower Hunt and Hess grade (OR 3.9; p < 0.001) and preadmission BBs (OR 4.5; p = 0.002) were negatively associated with cVSP. In multivariate analysis, LVWMA (OR 2.7; p = 0.002) and low LVEF (OR 1.1; p = 0.05) were independent predictors of in-hospital mortality. Low LVEF (OR 3.9; p = 0.05) independently predicted medically refractory cVSP. The in-hospital mortality rate was higher in patients with LVWMA (47.4% vs 14.8%; p < 0.001).

CONCLUSIONS

The study data suggest that preadmission therapy with BBs is associated with lower incidence of cVSP after aSAH. LV dysfunction was associated with higher medically refractory cVSP and in-hospital mortality. BB therapy may be considered after aSAH as a cardioprotective and cVSP preventive therapy.

A Phase I proof-of-concept and safety trial of sildenafil to treat cerebral vasospasm following subarachnoid hemorrhage

OBJECTIVE

Studies show that phosphodiesterase-V (PDE-V) inhibition reduces cerebral vasospasm (CVS) and improves outcomes after experimental subarachnoid hemorrhage (SAH). This study was performed to investigate the safety and effect of sildenafil (an FDA-approved PDE-V inhibitor) on angiographic CVS in SAH patients.

METHODS

A2-phase, prospective, nonrandomized, human trial was implemented. Subarachnoid hemorrhage patients underwent angiography on Day 7 to assess for CVS. Those with CVS were given 10 mg of intravenous sildenafil in the first phase of the study and 30 mg in the second phase. In both, angiography was repeated 30 minutes after infusion. Safety was assessed by monitoring neurological examination findings and vital signs and for the development of adverse reactions. For angiographic assessment, in a blinded fashion, pre- and post-sildenafil images were graded as "improvement" or "no improvement" in CVS. Unblinded measurements were made between pre- and post-sildenafil angiograms.

RESULTS

Twelve patients received sildenafil; 5 patients received 10 mg and 7 received 30 mg. There were no adverse reactions. There was no adverse effect on heart rate or intracranial pressure. Sildenafil resulted in a transient decline in mean arterial pressure, an average of 17% with a return to baseline in an average of 18 minutes. Eight patients (67%) were found to have a positive angiographic response to sildenafil, 3 (60%) in the low-dose group and 5 (71%) in the high-dose group. The largest degree of vessel dilation was an average of 0.8 mm (range 0-2.1 mm). This corresponded to an average percentage increase in vessel diameter of 62% (range 0%-200%).

CONCLUSIONS

The results from this Phase I safety and proof-of-concept trial assessing the use of intravenous sildenafil in patients with CVS show that sildenafil is safe and well tolerated in the setting of SAH. Furthermore, the angiographic data suggest that sildenafil has a positive impact on human CVS.

Cerebral vasodilator properties of Danshen and Gegen: a study of their combined efficacy and mechanisms of actions

Danshen and Gegen are two commonly used Chinese herbal medicines for treatment of cardiovascular diseases. The aim of the present study was to elucidate the combination effects of these two herbs on cerebral vascular tone and their underlying mechanisms of actions. Basilar artery rings were obtained from rats and precontracted with U46619. Cumulative administrations of aqueous extracts of Danshen, Gegen, or the two herbs combined (DG; ratio 7:3) produced concentration-dependent relaxation of the artery rings. Statistical analysis on these findings produced a combination index (CI) of 1.041 at ED50, which indicates the two herbs produced additive vasodilator effects when used as a combined decoction. Removal of the endothelium had no effect on the vasodilator properties of Danshen, Gegen, and DG. However, their maximum effects (Imax) were significantly blunted by a KATP channel inhibitor glibenclamide, a non-selective K(+) channel inhibitor tetraethylammonium (TEA), and by a combination of K(+) channel inhibitors (glibenclamide+TEA+iberiotoxin+4-aminopyridine+barium chloride). In addition, Danshen, Gegen, and DG produced augmentation of KATP currents and inhibited Ca(2+) influx in vascular smooth muscle cells isolated from rat basilar arteries. Furthermore, these agents inhibited CaCl2-induced contraction in the artery rings. In conclusion, the present study showed that Danshen and Gegen produced additive vasodilator effects on rat cerebral basilar arteries. These effects were independent of endothelium-derived relaxant factors (EDRF), but required the opening of KATP channels and inhibition of Ca(2+) influx in the vascular smooth muscle cells. It is suspected that the cerebral vasodilator effects of Danshen and Gegen produced either on their own or in combination, can help patients with obstructive cerebrovascular diseases.

A geometric scaling model for assessing the impact of aneurysm size ratio on hemodynamic characteristics

Background

The intracranial aneurysm (IA) size has been proved to have impacts on the hemodynamics and can be applied for the prediction of IA rupture risk. Although the relationship between aspect ratio and hemodynamic parameters was investigated using real patients and virtual models, few studies focused on longitudinal experiments of IAs based on patient-specific aneurysm models. We attempted to do longitudinal simulation experiments of IAs by developing a series of scaled models.

Methods

In this work, a novel scaling approach was proposed to create IA models with different aneurysm size ratios (ASRs) defined as IA height divided by average neck diameter from a patient-specific aneurysm model and the relationship between the ASR and hemodynamics was explored based on a simulated longitudinal experiment. Wall shear stress, flow patterns and vessel wall displacement were computed from these models. Pearson correlation analysis was performed to elucidate the relationship between the ASR and wall shear stress. The correlation of the ASR and flow velocity was also computed and analyzed.

Results

The experiment results showed that there was a significant increase in IA area exposed to low WSS once the ASR > 0.7, and the flow became slower and the blood was more difficult to flow into the aneurysm as the ASR increased. Meanwhile, the results also indicated that average blood flow velocity and WSS had strongly negative correlations with the ASR (r = −0.938 and −0.925, respectively). A narrower impingement region and a more concentrated inflow jet appeared as the ASR increased, and the large local deformation at aneurysm apex could be found as the ASR >1.7 or 0.7 < the ASR <1.0.

Conclusion

Hemodynamic characteristics varied with the ASR. Besides, it is helpful to further explore the relationship between morphologies and hemodynamics based on a longitudinal simulation by building a series of patient-specific aneurysm scaled models applying our proposed IA scaling algorithm.

Endovascular management of cerebral vasospasm following aneurysm rupture: outcomes and predictors in 116 patients

OBJECTIVE

To retrospectively assess the safety and efficacy of endovascular treatment of cerebral vasospasm with different modalities and assess predictors of outcome.

METHODS

Endovascular treatment was indicated in the event of neurological deterioration refractory to medical therapy. Data were collected for 116 patients treated at our institution.

RESULTS

Vasospasm was treated with balloon angioplasty in 52.6%, intra-arterial nicardipine infusion in 19.8%, or both in 27.6%. Angiographic vasospasm was reversed in all but 4 (96.6%) patients. The complication rate was 0.9%. Twenty patients (17.2%) had incipient pre-procedure hypodensities; 3 (15%) hypodensities were reversed and neurological improvement occurred in 60% of these patients. Retreatment was required in 22 (19%) patients. Higher Hunt and Hess grades and treatment with nicardipine alone predicted retreatment. Neurological improvement was noted in 82%. Male gender, pre-procedure hypodensities, and posterior communicating artery aneurysm location negatively predicted neurological recovery. Favorable outcomes were noted in 73%. Higher Hunt and Hess grades, pre-procedure hypodensities, posterior circulation aneurysms, and no neurological recovery predicted poor outcome.

CONCLUSION

Endovascular therapy for vasospasm has an excellent safety-efficacy profile. Balloon angioplasty and nicardipine are equally effective but effects of nicardipine are less durable. Patients with incipient pre-procedure hypodensities benefit from endovascular intervention and should probably not be excluded from treatment.

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.

Image-guided transcranial Doppler sonography for monitoring of defined segments of intracranial arteries

BACKGROUND

Transcranial Doppler sonography (TCD) is widely used in neurointensive care. Image guidance (IG) could simplify secure vessel identification and reduce interinvestigator and intrainvestigator variability. The present study was purposed to investigate the precision and reproducibility of image-guided TCD.

METHODS

The Kolibri IG system (Brainlab AG, Feldkirchen, Germany) was used to track a hand-held Doppler probe of a DWL Multi-Dop® T digital device (Compumedics Germany GmbH, Singen, Germany). The patient's head was registered noninvasively to the IG system. Distance between predefined vascular target and optimal Doppler signal was evaluated to assess spatial accuracy of image-guided TCD. To investigate reproducibility, spatial accuracy of trajectories acquired during an initial examination using the IG system was analyzed in serial examinations. Furthermore, stability of noninvasive registration of the patient's head to the IG system was analyzed. Data are presented as mean±SD for descriptive statistics. Twelve patients were included.

RESULTS

Using IG, a Doppler signal was recorded immediately in all cases for middle cerebral artery (MCA) (29 examinations), in 81% for carotid-T (27 examinations), and in 90% for basilar tip (29 examinations). The optimal Doppler signal was found within 2.64±1.15 mm (94 preplanned targets). At serial examinations, a spatial deviation of 2.75±1.20 mm was found (56 trajectories acquired in 19 serial examinations). Examination time did not influence accuracy of noninvasive patient registration.

CONCLUSIONS

Data suggest that image-guided TCD allows for accurate examinations with high intraprocedural and high interprocedural reproducibility. It facilitates identification of specific vessel segments and generation of standardized examination protocols for serial examinations.

Comparative Effectiveness of Unruptured Cerebral Aneurysm Therapies

Background and Purpose—

Endovascular therapy has increasingly become the most common treatment for unruptured cerebral aneurysms in the United States. We evaluated a national, multi-hospital database to examine recent utilization trends and compare periprocedural outcomes between clipping and coiling treatments of unruptured aneurysms.

Methods—

The Premier Perspective database was used to identify patients hospitalized between 2006 to 2011 for unruptured cerebral aneurysm who underwent clipping or coiling therapy. A logistic propensity score was generated for each patient using relevant patient, procedure, and hospital variables, representing the probability of receiving clipping. Covariate balance was assessed using conditional logistic regression. Following propensity score adjustment using 1:1 matching methods, the risk of in-hospital mortality and morbidity was compared between clipping and coiling cohorts.

Results—

A total of 4899 unruptured aneurysm patients (1388 clipping, 3551 coiling) treated at 120 hospitals were identified. Following propensity score adjustment, clipping patients had a similar likelihood of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 0.49–4.44; P =0.47) but a significantly higher likelihood of unfavorable outcomes, including discharge to long-term care (OR, 4.78; 95% CI, 3.51–6.58; P <0.0001), ischemic complications (OR, 3.42; 95% CI, 2.39–4.99; P <0.0001), hemorrhagic complications (OR, 2.16; 95% CI, 1.33–3.57; P <0.0001), postoperative neurological complications (OR, 3.39; 95% CI, 2.25–5.22; P <0.0001), and ventriculostomy (OR, 2.10; 95% CI, 1.01–4.61; P =0.0320) compared with coiling patients.

Conclusions—

Among patients treated for unruptured intracranial aneurysms in a large sample of hospitals in the United States, clipping was associated with similar mortality risk but significantly higher periprocedural morbidity risk compared with coiling.

Resistant vasospasm in subarachnoid hemorrhage treated with continuous intraarterial nimodipine infusion

Cerebral vasospasm complicating aneurysmal subarachnoid hemorrhage is a well-known medical entity. The delayed ischemic neurological deficits (DIND) as a result of vasospasm remain the main cause of morbidity among patients who manage to survive this severe disease pattern. When the traditional treatment options, either medical or interventional, fail to reverse vasospasm, continuous intraarterial infusion of nimodipine through catheters directly into the spastic arteries presents a promising treatment modality. Of 73 patients with aneurysmal subarachnoid hemorrhage between 2008 and 2009, a total of 27 had Hunt and Hess grades of 4 and 5. Fifteen percent of them showed refractory vasospasms and were treated with continuous nimodipine infusion via catheters in both internal carotid arteries. We present the method's indications and possible complications.

Endovascular treatment of medically refractory cerebral vasospasm following aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

CV following aneurysmal SAH is a significant cause of morbidity and mortality. We review our experiences using PTA and IA verapamil infusion for treating medically refractory cases.

MATERIALS AND METHODS

We performed a retrospective review of patients with SAH admitted from July 2003 to January 2008.

RESULTS

Of 546 patients admitted within 72 hours of symptom onset, 231 patients (42%) developed symptomatic CV and 189 patients (35%) required endovascular therapy. A total of 346 endovascular sessions were performed consisting of 1 single angioplasty, 286 IA verapamil infusions, and 59 combined treatments. PTA was performed on 151 vessel segments, and IA verapamil was infused in 720 vessel segments. IA verapamil doses ranged from 2.0 to 30.0 mg per vessel segment and from 3.0 to 55.0 mg per treatment session. Repeat treatments were necessary in 102 patients (54%) for persistent, recurrent, or worsening CV. There were 6 treatment-related complications, of which 2 resulted in clinical worsening. No deaths were attributable to endovascular therapy. At follow-up, 115 patients (61%) had a good outcome and 55 patients (29%) had a poor outcome. Sixteen patients died from causes related to SAH, while 3 died from other medical complications.

CONCLUSIONS

Endovascular treatments are an integral part of managing patients with medically refractory CV. In our experience, PTA and IA verapamil are safe, with a low complication rate, but further studies are required to determine appropriate patient selection and treatment efficacy.

A novel treatment of distal cerebral vasospasm. A case report

SUMMARY

A 22-year-old woman had an aneurysmal SAH due to a ruptured anterior communicating artery aneurysm and was treated successfully with endovascular coiling. The patient subsequently developed severe clinical and angiographically distal vasospasm. After failure of both medical treatment and proximal balloon angioplasty, the NeuroFlo device was tried and the patient showed substantial clinical recovery. We demonstrated an excellent outcome using a novel treatment for distal cerebral vasospasm with the NeuroFlo device.

Hemodynamic models of cerebral aneurysms for assessment of effect of vessel geometry on risk of rupture

Surgical decisions on treatment of cerebral aneurysms are based predominantly on aneurysm size. This study has assessed the influence of parent vessel geometry on intra-aneurysmal flow patterns and mass flow rate using computational fluid dynamics and finite element modeling of straight and curved vessels feeding saccular aneurysms of varying size and aspect ratio. Simulation results have shown that aneurysms of similar shape and size but with curved parent vessels can have more than 2 fold increase in flow rate, with markedly different flow velocity patterns and development of secondary flows. These are significant hemodynamic factors that can contribute to increased risk of aneurysm rupture, in addition to aneurysm size. The dependency of parent vessel geometry is a function of aneurysm aspect ratio and shows minimal dependency at an aspect ratio of 1.68. These findings could be used for improved quantification of risk of rupture of cerebral aneurysms detected from clinical imaging modalities and to aid surgical decision making.

Endovascular options in the treatment of delayed ischemic neurological deficits due to cerebral vasospasm

The second leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (SAH) is delayed cerebral ischemia due to vasospasm. Although up to 70% of patients have been shown to have angiographic evidence of vasospasm, only 20-30% will present with clinical changes, including mental status changes and neurological deficits that necessitate acute management. Endovascular capabilities have progressed to become viable options in the treatment of cerebral vasospasm. The rationale for intraarterial therapy includes the fact that morbidity and mortality rates have not changed in recent years despite optimized noninvasive medical care. In this report, the authors discuss the most common endovascular options-namely intraarterial vasodilators and transluminal balloon angioplasty-from the standpoint of mechanism, efficacy, limitations, and complications as well as the treatment algorithms for cerebral vasospasm used at our institution.