Efficacy of multiple intraarterial papaverine infusions for improvement in cerebral circulation time in patients with recurrent cerebral vasospasm

Pathological migrating intramural hematoma in stenting for carotid artery dissection: A ten-year consecutive cohort study

OBJECTIVE

To study the phenomenon, incidence and management of pathological migrating intramural hematoma in stenting for carotid artery dissection.

METHODS

We consecutively enrolled CAD patients with stenting treatment over 10-year period, and retrospectively analyzed the pathological migrating intramural hematoma (PMIH) incidence of these CAD patients. Besides, we also explored the related factors with PMIH and provided an appropriate management strategy.

RESULTS

A total of 67 CAD underwent stenting. PMIH occurred in 7 cases (10.4%). The median time from onset of symptoms to stenting was 5 days (3 to 11 days). There were 4 cases of PMIH in the proximal segment of stent and 3 cases of PMIH in the distal segment of stent. All the patients presented with new stenosis and no patient presented with dissecting aneurysm. Through proper management, none of the patients had occurred clinical complications.

CONCLUSION

Pathological migrating intramural hematoma phenomenon exists in the stenting for carotid artery dissection, rescue angioplasty or stenting is needed for early treatment of moderate and severe stenosis due to migrating intramural hematoma on preventing further ischemic events.

A randomized, single ascending dose safety, tolerability and pharmacokinetics study of NicaPlant® in aneurysmal subarachnoid hemorrhage patients undergoing clipping

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Post-hemorrhagic vasospasm with neurological deterioration is a major concern in this context. NicaPlant®, a modified release formulation of the calcium channel blocker nicardipine, has shown vasodilator efficacy preclinically and a similar formulation known as NPRI has shown anti-vasospasm activity in aSAH patients under compassionate use.

Research question

The study aimed to assess pharmacokinetics and pharmacodynamics of NicaPlant® pellets to prevent vasospasm after clip ligation in aSAH.

Material and methods

In this multicenter, controlled, randomized, dose escalation trial we assessed the safety and tolerability of NicaPlant®. aSAH patients treated by clipping were randomized to receive up to 13 NicaPlant® implants, similarly to the dose of NPRIs previous used, or standard of care treatment.

Results

Ten patients across four dose groups were treated with NicaPlant® (3-13 implants) while four patients received standard of care. 45 non-serious and 13 serious adverse events were reported, 4 non-serious adverse events and 5 serious adverse events assessed a probable or possible causal relationship to the investigational medical product. Across the NicaPlant® groups there was 1 case of moderate vasospasm, while in the standard of care group there were 2 cases of severe vasospasm.

Discussion and conclusion

The placement of NicaPlant® during clip ligation of a ruptured cerebral aneurysm raised no safety concern. The dose of 10 NicaPlant® implants was selected for further clinical studies.

Predictive factors for improvement of symptomatic cerebral vasospasm following subarachnoid hemorrhage by selective intra-arterial administration of fasudil hydrochloride

BACKGROUND

Symptomatic cerebral vasospasm after subarachnoid hemorrhage (SAH) is a significant cause of delayed cerebral ischemia that leads to poor outcomes. Selective intra-arterial administration of fasudil hydrochloride (IAF) has been adopted for its vasodilatory effect on spasm arteries to prevent delayed cerebral ischemia. However, its effect on clinical outcomes and predictive factors for good recovery are not fully understood. This study aimed to investigate the outcomes of selective IAF and identify predictive factors for good outcomes in patients with cerebral vasospasm after SAH.

METHODS

A retrospective study of 36 patients with cerebral vasospasm following SAH who underwent selective IAF at our institution between January 2014 and May 2022 was conducted. We evaluated the improvements in neurological findings before and after selective IAF. Statistical analyses were performed to determine factors associated with good outcomes.

RESULTS

Selective IAF improved the neurological findings in 26 patients (72.2%). Pre-therapeutic absence of cerebral infarction in more than 1/3 of the spasm artery perfusion area was significantly associated with an improvement in neurological findings (p < 0.0001). Furthermore, there was a tendency for a good outcome when the age was younger (p = 0.093), and the spasm was limited to peripheral vessels (p = 0.065).

CONCLUSION

Our study indicates that selective IAF has a promising effect in improving symptomatic vasospasm, except when a large cerebral infarction exists in the spasm artery perfusion area. Early consideration of selective IAF could be recommended once patients experience symptomatic cerebral vasospasm after SAH.

Hematological biomarkers for predicting carotid artery vasospasm during carotid stenting

Introduction

The vasospasm of carotid arteries is important for the progression of neurological sequelae. Many mechanisms have been found to be related to this clinical phenomenon. Predicting this event by using hematological biomarkers may provide opportunities for adopting preventive measures against unfavorable neurovascular complications. The aim of this study is to determine the hematological predictors of carotid artery vasospasm during carotid stenting.

Material and methods

A total of 120 patients who underwent carotid stenting were divided into two groups: those with and without carotid artery vasospasm. Carotid artery vasospasm was angiographically defined as transient or persistent emergent stenosis or irregularity of the vessel wall without evidence of thrombosis during carotid stenting. The hematological parameters were compared between 21 patients who developed carotid artery vasospasm (17.5%) and 99 patients who did not (82.5%).

Results

The mean age of the patients with carotid artery vasospasm and without carotid artery vasospasm was 66 ±8 and 70 ±8 years, respectively. Creatinine levels within 0.5–0.9 (OR = 3.704, 95% CI: 1.245–11.019, p = 0.019), each 1000 unit increase in neutrophil count (OR = 1.567, 95% CI: 1.027–2.392, p = 0.037) and presence of diabetes (OR = 3.081, 95% CI: 1.116–8.505, p = 0.030) were the independent predictors of carotid artery vasospasm in carotid arteries during carotid stenting.

Conclusions

The prediction of carotid artery vasospasm during carotid stenting should help clinicians adopt preventive measures against the development of neurological sequelae. This study found that creatinine levels, increased neutrophil count and presence of diabetes are independent predictors of carotid artery vasospasm.

Endovascular Rescue Therapies for Refractory Vasospasm After Subarachnoid Hemorrhage: A Prospective Evaluation Study Using Multimodal, Continuous Event Neuromonitoring

BACKGROUND

Critical hypoperfusion and metabolic derangement are frequently encountered with refractory vasospasm. Endovascular rescue therapies (ERT) have proven beneficial in selected cases. However, angioplasty (AP) and intraarterial lysis (IAL) are measures of last resort and prospective, quantitative results regarding the efficacy (cerebral oxygenation, metabolism) are largely lacking.

OBJECTIVE

To evaluate the efficacy of ERTs for medically refractory vasospasm using multimodal, continuous event neuromonitoring.

METHODS

To detect cerebral compromise in a timely fashion, sedated patients with aneurysmal subarachnoid hemorrhage received continuous neuromonitoring (p ti O 2 measurement, intraparenchymal microdialysis). ERT (AP and/or IAL) was considered in cases of clinically relevant vasospasm refractory to conservative treatment measures. Oxygen saturation and cerebral and systemic metabolism before and after events of ERT was recorded.

RESULTS

We prospectively included 13 consecutive patients and recorded a total of 25 ERT events: AP (n = 10), IAL (n = 11), or both (AP + IAL, n = 4). Average cerebral p ti O 2 was 10 ± 11 torr before and 49 ± 22 torr after ERT ( P < .001), with a lactate-pyruvate ratio decreasing from 146.6 ± 119.0 to 27.9 ± 10.7 after ERT ( P < .001). Comparable improvement was observed for each type of intervention (AP, IAL, or both). No significant alterations in systemic metabolism could be detected after ERT.

CONCLUSION

Multimodal event neuromonitoring is able to quantify treatment efficacy in subarachnoid hemorrhage-related vasospasm. In our small cohort of highly selected cases, ERT was associated with improvement in cerebral oxygenation and metabolism with reasonable outcome. Event neuromonitoring may facilitate individual and timely optimization of treatment modality according to the individual clinical course.

Continuous intra-arterial nimodipine infusion in patients with severe refractory cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a feasibility study and outcome results

BACKGROUND

Severe cerebral vasospasm is a major cause of death and disability in patients with aneurysmal subarachnoid hemorrhage. No causative treatment is yet available and hypertensive hypervolemic therapy (HHT) is often insufficient to avoid delayed cerebral ischemia and neurological deficits. We compared patients receiving continuous intra-arterial infusion of the calcium-antagonist nimodipine with a historical group treated with HHT and oral nimodipine alone.

METHODS

Between 0.5 and 1.2 mg/h of nimodipine were continuously administered by intra-arterial infusion via microcatheters either into the internal carotid or vertebral artery or both, depending on the areas of vasospasm. The effect was controlled via multimodal neuromonitoring and transcranial Doppler sonography. Outcome was determined by means of the Glasgow Outcome Scale at discharge and 6 months after the hemorrhage and compared to a historical control group.

RESULTS

Twenty-one patients received 28 intra-arterial nimodipine infusions. Six months after discharge, the occurrence of cerebral infarctions was significantly lower (42.6 %) in the nimodipine group than in the control group (75.0 %). This result was reflected by a significantly higher proportion (76.0 %) of patients with good outcome in the nimodipine-treated group, when compared to 10.0 % good outcome in the control group. Median GOS was 4 in the nimodipine group and 2 in the control group (p = 0.001).

CONCLUSIONS

Continuous intra-arterial nimodipine infusion is an effective treatment for patients with severe cerebral vasospasm who fail to respond to HHT and oral nimodipine alone. Key to the effective administration of continuous intra-arterial nimodipine is multimodal neuromonitoring and the individual adaptation of dosage and time of infusion for each patient.

Cerebral vasospasm

Cerebral vasospasm causes delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage. This is a well-established clinical entity with significant associated morbidity and mortality. The underlying patholphysiology is highly complex and poorly understood. Large-vessel vasospasm, autoregulatory dysfunction, inflammation, genetic predispositions, microcirculatory failure, and spreading cortical depolarization are aspects of delayed neurologic deterioration that have been described in the literature. This article presents a perspective on cerebral vasospasm, as guided by the literature to date, specifically examining the mechanism, diagnosis, and treatment of cerebral vasospasm.

Cerebral Vasospasm in Critically III Patients with Aneurysmal Subarachnoid Hemorrhage: Does the Evidence Support the Ever-Growing List of Potential Pharmacotherapy Interventions?

The occurrence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) is a significant event resulting in decreased cerebral blood flow and oxygen delivery. Prevention and treatment of cerebral vasospasm is vital to avert neurological damage and reduced functional outcomes. A variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm have been evaluated. Unfortunately, very few large randomized trials exist to date, making it difficult to make clear recommendations regarding the efficacy and safety of most pharmacologic interventions. Considerable debate exists regarding the efficacy and safety of hypervolemia, hemodilution, and hypertension (triple-H therapy), and the implementation of each component varies substantially amongst institutions. There is a new focus on euvolemic-induced hypertension as a potentially preferred mechanism of hemodynamic augmentation. Nimodipine is the one pharmacologic intervention that has demonstrated favorable effects on patient outcomes and should be routinely administered unless contraindications are present. Intravenous nicardipine may offer an alternative to oral nimodipine. The addition of high-dose magnesium or statin therapy has shown promise, but results of ongoing large prospective studies are needed before they can be routinely recommended. Tirilazad and clazosentan offer new pharmacologic mechanisms, but clinical outcome results from prospective randomized studies have largely been unfavorable. Locally administered pharmacotherapy provides a targeted approach to the treatment of cerebral vasospasm. However, the paucity of data makes it challenging to determine the most appropriate therapy and implementation strategy. Further studies are needed for most pharmacologic therapies to determine whether meaningful efficacy exists.

Intra-arterial administration of papaverine during mechanical thrombectomy for acute ischemic stroke

BACKGROUND

The use of stent retrievers for mechanical thrombectomy in acute ischemic stroke may induce significant vasospasm, which at the early phases of reperfusion may be crucial for rethrombosis of the recanalized vessel. We aimed to study whether the use of intra-arterial papaverine in selected cases of vasospasm was associated with improved cerebral perfusion, arterial reocclusion, or increased hemorrhagic complications.

METHODS

We retrospectively studied 9 consecutive patients with large artery acute occlusion, treated with stent retriever and intra-arterial papaverine. Onset to administration of intravenous recombinant tissue-plasminogen activator time, baseline National Institute of Health Stroke Scale, time to reperfusion, number of passes of the stent retriever, modified Rankin Scale score at discharge, postprocedural hemorrhage, onset to reperfusion time, papaverine dose, and thrombolysis in cerebral infarction grade were recorded in all patients.

RESULTS

After papaverine administration, the caliber of the infused arteries and their flow was increased in all cases. In none of the treated cases a reocclusion occurred after papaverine infusion. In one of the studied patients (11%), a parenchymal bleeding occurred 36 hours postoperatively.

CONCLUSIONS

This small study suggests that intra-arterial infusion of papaverine for the treatment of cerebral vasospasm after mechanical thrombectomy in acute ischemic stroke is effective and safe.

Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature

OBJECTIVES

Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment.

METHODS

A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion.

RESULTS

Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established.

CONCLUSION

Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.

Prophylactic intra-arterial injection of vasodilator for asymptomatic vasospasm converts the patient to symptomatic vasospasm due to severe microcirculatory imbalance

OBJECT

The strategy to treat asymptomatic angiographic vasospasm following subarachnoid hemorrhage (SAH) is controversial. In this study we review our consecutive vasospasm series and discuss an adequate treatment strategy for asymptomatic vasospasm.

METHODS

From January 2007 to December 2012 we treated 281 aneurysmal SAH cases, with postoperative angiography performed 9 ± 2 days after the onset of SAH. Four asymptomatic cases received intra-arterial (IA) injection of vasodilator due to angiographic vasospasm. All cases improved vasospasm immediately following intervention. But all cases turned symptomatic within 48 hours. We retrospectively analyzed the time-density angiography curve and calculated the time to peak (TTP), mean transit time (MTT), and relative blood flow (rBF). Relative blood flow was calculated as follows. The integration of the value of the time-density curve for the artery was divided by the same value for the internal carotid artery multiplied by the MTT.

RESULTS

The decrease in TTP and MTT for the etiologic artery was similar to that of the nonetiologic artery. But the improvement in rBF for the etiologic artery and nonetiologic artery was 10% and 17%, respectively. Blood supply to the spastic artery decreased due to iatrogenic steal.

CONCLUSION

Prophylactic IA injection of vasodilator in cases of asymptomatic vasospasm can produce symptomatic vasospasm.

Pharmacologic Options for Prevention and Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Background

Cerebral vasospasm and delayed cerebral ischemia continue to be major contributors to morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH).

Purpose

The purpose of this review was to evaluate the pharmacotherapy interventions for the prevention and management of cerebral vasospasm in patients with SAH.

Methods

A search of MEDLINE (January 1966-April 2012) and EMBASE (January 1974-April 2012) was conducted to retrieve relevant studies of pharmacotherapy options for prevention or treatment of cerebral vasospasm in SAH.

Results

Triple-H therapy (hypervolemia, hemodilution, hypertension) has been a widely accepted option by many clinicians for the management of cerebral vasospasm and delayed cerebral ischemia. However, implementation of Triple-H therapy varies considerably at individual institutions. Nimodipine and nicardipine have demonstrated the most dependable improvements in patient outcomes to date. High doses of intravenous magnesium have failed to show consistent benefits. Magnesium supplementation to prevent hypomagnesaemia should be employed. Statin therapy should be continued in patients who are taking statins prior to hospital admission. Use of statins in naive patients may be recommended when the results of an ongoing prospective study are available. Of the available locally administered pharmacologic therapies, nicardipine and thrombolytics appear to provide the most intriguing benefit-to-risk ratio. However, the data supporting the use of locally administered therapy are modest at best and require careful consideration prior to application.

Conclusions

Clinical studies have tested a variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm. Of available therapies, nimodipine has demonstrated consistent benefits and should be employed routinely. Demonstration of reduced cerebral vasospasm and improved neurological outcomes in larger prospective studies are needed for most pharmacologic therapy options prior to recommending their routine use.

Clinical investigation of fasudil for the prevention of cerebral vasospasm in extracranial carotid artery stenting

To evaluate fasudil hydrochloride for the prevention of cerebral vasospasm (CVS) in extra-cranial carotid angioplasty and stenting (CAS). We retrospectively analyzed 178 patients with unilateral CAS who were given intravenous fasudil hydrochloride during the perioperative period. CVS, hypotension, stroke, and mortality incidence rates were recorded. Of the cohort studied, 80.9 % patients exhibited no local CVS, asymptomatic vasospasm was observed in 17.4 % patients and symptomatic vasospasm in 1.7 % patients via DSA imaging. All CVS was relieved and symptoms disappeared after intra-arterial infusion of papaverine hydrochloride. Intracerebral hemorrhage occurred in two cases during the perioperative period, one of which resulted in death. CVS is a severe complication of CAS. Fasudil hydrochloride can rapidly relieve cerebral vasospasm, has no selective effect on cerebral vasculature, and little influence on blood pressure. It is suitable for the prevention of CVS during interventional treatment of ischemic cerebrovascular disease.

Role of simvastatin in prevention of vasospasm and improving functional outcome after aneurysmal sub-arachnoid hemorrhage: a prospective, randomized, double-blind, placebo-controlled pilot trial

BACKGROUND

Vasospasm plays a major role in the morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The preliminary studies suggest that statins protect against cerebral vasospasm.

OBJECTIVE

The aim of the study was to determine the role of simvastatin in preventing clinical vasospasm and improving functional outcome in patients with aSAH.

METHODS

All patients with aSAH admitted within 96 h of ictus were randomized to receive either Simvastatin or placebo - 80 mg/day for 14 days. Thirty eight patients were recruited in the study- 19 received Simvastatin and 19 placebo. All the patients underwent surgical clipping of the aneurysm. The primary outcome of the study was the development of clinical cerebral vasospasm. The secondary outcomes included Glasgow Outcome Score (GOS), Modified Rankin Scale (MRS) and Barthel Index Score (MBI) at follow-up at 1, 3 and 6 months.

RESULTS

16% of the patients in the simvastatin group had high Middle Cerebral Artery velocities (> 160 cm/sec) on transcranial Doppler on one or more than one day during the study duration as compared to 26% of the patients in the placebo group (p = 0.70). Neurological deterioration occurred in 26% and 42% of the patients in simvastatin group versus placebo group, respectively (p = 0.31). There was an improvement in the functional outcome in the simvastatin group at 1, 3 or 6 months in the follow-up; however, this difference was not statistically significant.

CONCLUSIONS

There was benefit of simvastatin in terms of reduction in clinical vasospasm, mortality or improved functional outcome, however, this was not statistically significant.

Critical care guidelines on the endovascular management of cerebral vasospasm

Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.

Intra-arterial nimodipine infusion for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage

This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.

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.

Recurrent vasospasm after endovascular treatment in subarachnoid hemorrhage

OBJECTIVES

the frequency and predictors of recurrent symptomatic and angiographic vasospasm after angioplasty or intra-arterial chemical vasodilatation (IACV) in patients with subarachnoid hemorrhage (SAH) are not well characterized.

METHODS

a retrospective review of serial clinical and angiographic data was conducted between 7/2001-6/2008 on spontaneous SAH patients who underwent endovascular therapy for symptomatic vasospasm.

RESULTS

of 318 SAH patients, symptomatic vasospasm occurred in 80 (25%) and endovascular intervention was performed on 69 (22%) patients. Of these 69 patients, all received IACV in 274 vessels and 33 also underwent angioplasty in a total of 76 vessels. Recurrent angiographic vasospasm occurred in the same vessel segment in 9/23 (39%) patients who received both angioplasty + IACV compared to 40/49 (82%) of patients who received IACV alone (P < 0.001). Recurrent symptomatic vasospasm occurred in 10/26 (38%) angioplasty + IACV patients compared to 28/37 (76%) patients who received IACV alone (P = 0.003). The modified-Fisher Score, A1 spasm, distal and multi-vessel vasospasm predicted recurrent angiographic spasm after IACV alone (P < 0.05). Procedural complications occurred in 4% of IACV alone patients and 6% of angioplasty + IACV patients (P = 0.599).

CONCLUSIONS

recurrent angiographic or symptomatic vasospasm is not uncommon after angioplasty + IACV, but appears to occur significantly less than after IACV alone, without any increase in procedural complications.

Procedural predictors of delayed cerebral infarction after intra-arterial vasodilator infusion for vasospasm following aneurysmal subarachnoid hemorrhage

PURPOSE

The goals of this study were to identify predictors of delayed cerebral infarction in aneurysmal SAH after intra-arterial (IA) vasodilator infusion and to select proper parameters for treatment success.

METHODS

Forty-three patients qualified for review. Cerebral infarction was determined by DWI within 1 week of angiographic vasospasm.

RESULTS

Infarction developed in 18 of the 43 patients (41.9%) after IA vasodilator infusion and was associated with a high degree of proximal vessel residual narrowing and angiographic cerebral circulation time (CCT) prolongation at the end of IA vasodilator infusion (p < 0.001). A high degree of proximal residual narrowing (p = 0.018; odds ratio = 1.071; 95% confidence interval [CI] 1.012-1.123) and CCT prolongation at the end of the procedure (p = 0.007; odds ratio = 2.203; 95% CI 1.254-4.232) were found to be predictors of infarction by multivariate analysis. Furthermore, receiver operating characteristic (ROC) curves showed that both variables predicted the development of infarction (proximal vessel residual narrowing, area under the ROC curve [AUC], 0.828; CCT, AUC, 0.866). When proximal vessel narrowing of >30% or a CCT of >7 s by final angiography during IA vasodilator infusion were used as a threshold, the negative predictive value for infarction was 88.9% (95% CI 65.3-98.6%), and when narrowing was >30% and CCT was >7 s, the probability of subsequent cerebral infarction was 100% (95% CI 71.7-100%).

CONCLUSIONS

Angiographic CCT and residual narrowing at the end of IA vasodilator infusion were found to predict the subsequent occurrence of cerebral infarction. The authors suggest that residual narrowing of 30% and a CCT of 7 s could be used as a minimum indicator of IA vasodilator infusion endpoints.

Continuous selective intraarterial infusion of nimodipine for therapy of refractory cerebral vasospasm

BACKGROUND

For endovascular treatment of vasospasm after aneurysmal subarachnoid hemorrhage (aSAH), an intraarterial treatment course with the calcium channel antagonist nimodipine infused for 30 min is proposed. As some patients still show ongoing vasospasm thereafter, we report on our experience with an extended time period of selective intraarterial nimodipine administration.

METHODS

In nine patients with aSAH and refractory cerebral vasospasm, we left the catheter in place within the internal carotid artery after angiography. On the neurosurgical ICU, a continuous infusion of intraarterial nimodipine was commenced, combined with intraarterial heparin anticoagulation. Therapy was controlled with extended neuromonitoring techniques.

RESULTS

Three patients died from refractory vasospasm and a fourth suffered lethal sepsis. Three patients survived in a good clinical condition, two of them without apparent neurologic deficit. The efficacy of intraarterial nimodipine was best verified with regional CBF monitoring. TCD failed to detect vasospasm in two patients and missed improvement in four. Brain tissue oxygenation increased in all patients, but was not indicative of vasospasm in one. CT perfusion reflected the treatment course adequately in the qualitative scans.

CONCLUSION

Selective continuous intraarterial nimodipine treatment for refractory cerebral vasospasm after aSAH seems feasible and may add to the endovascular therapeutic options. Appropriate monitoring technology is essential for further investigation of this novel technique.

Therapeutic approaches to cerebral vasospasm complicating ruptured aneurysm

Cerebral vasospasm is a serious complication of ruptured aneurysm. In order to avoid short- and long-term effects of cerebral vasospasm, and as there is no single or optimal treatment modality employed, we have instituted a protocol for the prevention and treatment of vasospasm in patients suffering aneurysmal sub-arachnoid hemorrhage (SAH). We then reviewed the effectiveness of this protocol in reducing the mortality and morbidity rate in our institution. In this study we present a retrospective analysis of 52 cases. Between March 2004 and December 2008 52 patients were admitted to our service with aneurysmal SAH. All patients commenced nimodipine, magnesium sulphate (MgSO₄) and triple H therapy. Patients with significant reduction in conscious level were intubated, ventilated and sedated. Intracranial pressure (ICP) monitoring was used for intubated patients. Sodium thiopental coma was induced for patients with refractory high ICP; angiography was performed for diagnosis and treatment. Balloon angioplasty was performed if considered necessary. Using this protocol, only 13 patients (25%) developed clinical vasospasm. Ten of them were given barbiturates to induce coma. Three patients underwent transluminal balloon angioplasty. Four out of 52 patients (7.7%) died from severe vasospasm, 3 patients (5.8%) became severely disabled, and 39 patients (75%) were discharged in a condition considered as either normal or near to their pre-hemorrhage status. Our results confirm that the aforementioned protocol for treatment of cerebral vasospasm is effective and can be used safely.

Synthesis, acoustic stability, and pharmacologic activities of papaverine-loaded echogenic liposomes for ultrasound controlled drug delivery

BACKGROUND

development of encapsulated therapeutics that could be released upon ultrasound exposure has strong implications for enhancing drug effects at the target site. We have developed echogenic liposomes (ELIP) suitable for ultrasound imaging of blood flow and ultrasound-mediated intravascular drug release. Papaverine was chosen as the test drug because its clinical application requires high concentration in the target vascular bed but low concentration in the systemic circulation.

METHODS

the procedure for preparation of standard ELIP was modified by including Papaverine hydrochloride in the lipid hydration solution, followed by three freeze-thaw cycles to increase encapsulation of the drug. Sizing and encapsulation pharmacokinetics were performed using a Coulter counter and a phosphodiesterase activity assay. Stability of Papaverine-loaded ELIP (PELIP) was monitored with a clinical diagnostic ultrasound scanner equipped with a linear array transducer at a center frequency of 4.5 MHz by assessing the mean digital intensity within a region of interest over time. The stability of PELIP was compared to those of standard ELIP and Optison.

RESULTS

relative to standard ELIP, PELIP were larger (median diameter = 1.88 +/- 0.10 microm for PELIP vs 1.08 +/- 0.15 microm for ELIP) and had lower Mean Gray Scale Values (MGSV) (92 +/- 24.8 for PELIP compared to 142.3 +/- 10.7 for ELIP at lipid concentrations of 50 microg/ml). The maximum loading efficiency and mean encapsulated concentration were 24% +/- 7% and 2.1 +/- 0.7 mg/ml, respectively. Papaverine retained its phosphodiesterase inhibitory activity when associated with PELIP. Furthermore, a fraction of this activity remained latent until released by dissolution of liposomal membranes with detergent. The stability of both PELIP and standard ELIP were similar, but both are greater than that of Optison.

CONCLUSIONS

our results suggest that PELIP have desirable physical, biochemical, biological, and acoustic characteristics for potential in vivo administration and ultrasound-controlled drug delivery.

Evidence-based pharmacotherapy for cerebral vasospasm

INTRODUCTION

The vast amount of literature on the pharmaceutical treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage remains daunting. Optimal treatment regimens for patients can be obscured by studies not statistically powered to draw evidenced-based conclusions.

METHODS

In this chapter, we reviewed the English literature using the National Library of Medicine for studies regarding pharmacotherapies for the treatment of cerebral vasospasm. These studies were then categorized according to the US Preventative Services Task Force ranking system for evidence based medicine and reviewed each pharmacotherapy for its efficacy in the treatment of cerebral vasospasm.

RESULTS

Nimodipine (Nimotop), HMG Co-A reductase inhibitor (statins) and enoxaparin (Lovenox) were the only drugs with level-1 evidence available for the treatment of vasospasm from aneurysmal subarachnoid hemorrhage as defined by the US Preventative Services Task Force.

CONCLUSION

As the understanding of the pathophysiological mechanisms of vasospasm after aneurysmal subarachnoid hemorrhage evolves in the basic science laboratory, novel medications are being trialed in humans. However, significantly more work must be carried out in this area before we have an effective medical treatment that can prevent or reverse the devastating events of cerebral vasospasm.

Abnormal responses of the human cerebral microcirculation to papaverin during aneurysm surgery

BACKGROUND AND PURPOSE

The role of the cerebral microcirculation in delayed ischemia after subarachnoid hemorrhage remains obscure. To test the hypothesis that cerebral arterioles have a reduced capacity to dilate after subarachnoid hemorrhage, we studied the microvascular responses to papaverine (PPV) in patients undergoing aneurysm surgery. Method- In 14 patients undergoing aneurysm surgery, the diameter changes of cortical microvessels after topical application of PPV were observed using orthogonal polarizing spectral imaging.

RESULTS

In control subjects, neither arterioles nor venules showed diameter changes in response to topical PPV. In patients operated <48 hours after subarachnoid hemorrhage, PPV resulted in vasodilatation of arterioles with 45+/-41% increase in arteriolar diameter (P=0.012). In 2 of these patients, arteriolar diameter returned below baseline value. In patients undergoing late aneurysm clipping, the diameter increase of the arterioles after PPV was 25+/-24% (not significant). In 2 patients of this group, no vasodilatation but focal arteriolar narrowing occurred.

CONCLUSIONS

In patients with subarachnoid hemorrhage, unpredictable response patterns to PPV were observed with "rebound" vasoconstriction suggesting increased contractility of the microcirculation. Yet, diminished vasodilatory capacity of the cerebral microcirculation after subarachnoid hemorrhage was not confirmed by this study.

The effect of intra-arterial papaverine on ECoG activity in the ketamine anesthetized rat

The opium alkaloid papaverine (PPV) causes vasodilatation of the cerebral arteries through direct action on smooth muscle that reduces the constriction of smooth muscle. Intra-arterial papaverine (IAP) has been used widely to increase the regional cerebral blood flow in order to reverse the cerebral vasospasm that occurs during endovascular procedures. IAP-induced seizures have been reported, although PPV has anticonvulsive effects. This study determined the effects of IAP on electrocorticography (ECoG) in the ketamine anesthetized rats. We used 24 Sprague-Dawley male rats weighing 200-250 g. The animals were divided randomly into four groups: three treatment groups (groups 1-3) and a control (group 4). Groups 1, 2, and 3 were given 1, 7, and 14 mg/kg IAP, respectively. The ECoG was compared across groups. Our results indicated that IAP did not cause seizures and that it decreased the frequency of ketamine-induced epileptiform activity in the 14 mg/kg group.

Biological effects of acute pravastatin treatment in patients after aneurysmal subarachnoid hemorrhage: a double-blind, placebo-controlled trial

OBJECT

The authors previously demonstrated that acute pravastatin therapy in patients after aneurysmal subarachnoid hemorrhage (SAH) ameliorates vasospasm-related delayed ischemic neurological deficits. The object of this study was to continue to examine potential mechanisms of these beneficial effects.

METHODS

Eighty patients with aneurysmal SAH (age range 18-84 years; time to onset 1.8 +/- 1.3 days) were enrolled in a double-blind study and randomized to receive 40 mg of oral pravastatin or placebo daily for as long as 14 days. Daily transcranial Doppler ultrasonography and blood tests every 3 days (including full blood cell counts, coagulation profiles, fasting glucose and lipid profiles, and serum biochemistry) were performed during the trial period.

RESULTS

No significant differences were found in baseline laboratory data between the trial groups. Subsequent measurements during the 14-day trial showed reduced low-density lipoprotein (LDL) cholesterol levels and total/high-density lipoprotein cholesterol ratios between Days 3 and 15 (p < 0.05), and increased D-dimer levels (p < 0.05) on Day 6, in the pravastatin group. Patients who received pravastatin but developed vasospasm had significantly lower baseline LDL cholesterol levels or a less extensive reduction in LDL cholesterol levels (p < 0.05), and greater increases in plasma fibrinogen (p = 0.009) and serum C-reactive protein on Day 3 (p = 0.007), compared with those patients without vasospasm. The reduction in LDL cholesterol levels on Day 3 in the placebo group correlated with the duration of normal cerebral autoregulation on the ipsilateral side of the ruptured aneurysm (p = 0.002).

CONCLUSIONS

In addition to functioning through a cholesterol-independent pathway, cerebrovascular protection from acute statin therapy following aneurysmal SAH may also function through cholesterol-dependent mechanisms.

ADMISSION ANGIOGRAPHIC CEREBRAL CIRCULATION TIME MAY PREDICT SUBSEQUENT ANGIOGRAPHIC VASOSPASM AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

OBJECTIVE

Angiographic cerebral vasospasm occurs in approximately 70% of patients hospitalized after aneurysmal subarachnoid hemorrhage (SAH) and is associated with poor outcome. In this study, we examined whether or not cerebral circulation time (CCT) measured with digital subtraction angiography was associated with angiographic vasospasm.

METHODS

Patients who underwent cerebral angiography within 24 hours of SAH were analyzed. Contrast dye transit time from the arterial to the venous phase was measured to obtain CCT (supraclinoid internal carotid artery to parietal cortical veins) and microvascular CCT (cortical middle cerebral artery to parietal cortical veins). Patients with ruptured anterior circulation aneurysms and vasospasm on follow-up angiography (Group A) were compared with patients with SAH without vasospasm (Group B) and with normal control subjects (Group C).

RESULTS

There were 20 patients in Group A (mean age, 51 ± 13 yr), 17 patients in Group B (56 ± 12 yr), and 98 patients in Group C (52 ± 12 yr). CCT in patients in Group A (7.7 ± 1.9 s) was significantly longer than those in Groups B (6.6 ± 1.2 s; P = 0.005) and C (5.9 ± 1 s; P &lt; 0.001). Microvascular CCT in patients in Group A (7.1 ± 1.8 s) was significantly longer than those in Groups B (6.1 ± 1.2 s; P = 0.003) and C (5.4 ± 0.9 s; P &lt; 0.001).

CONCLUSION

Prolonged CCT, a measurement of increased small vessel resistance, can be identified within 24 hours after SAH and is associated with subsequent angiographic vasospasm. These results suggest that microcirculation changes may be involved in vasospasm.

Enhancement of cerebral blood flow using systemic hypertonic saline therapy improves outcome in patients with poor-grade spontaneous subarachnoid hemorrhage

OBJECT

Systemic administration of 23.5% hypertonic saline enhances cerebral blood flow (CBF) in patients with poor-grade spontaneous subarachnoid hemorrhage (SAH). Whether the increment of change in CBF correlates with changes in autoregulation of CBF or outcome at discharge remains unknown.

METHODS

Thirty-five patients with poor-grade spontaneous SAH received 2 ml/kg 23.5% hypertonic saline intravenously, and they underwent bedside transcranial Doppler (TCD) ultrasonography and intracranial pressure (ICP) monitoring. Seventeen of them underwent Xe-enhanced computed tomography (CT) scanning for measuring CBF. Outcome was assessed using the modified Rankin Scale (mRS) at discharge from the hospital. The data were analyzed using repeated-measurement analysis of variance and Dunnett correction. A comparison was made between patients with favorable and unfavorable outcomes using multivariate logistic regression.

RESULTS

The authors observed a maximum increase in blood pressure by 10.3% (p < 0.05) and cerebral perfusion pressure (CPP) by 21.2% (p < 0.01) at 30 minutes, followed by a maximum decrease in ICP by 93.1% (p < 0.01) at 60 minutes. Changes in ICP and CPP persisted for longer than 180 and 90 minutes, respectively. The results of TCD ultrasonography showed that the baseline autoregulation was impaired on the ipsilateral side of ruptured aneurysm, and increments in flow velocities were higher and lasted longer on the contralateral side (48.75% compared with 31.96% [p = 0.045] and 180 minutes compared with 90 minutes [p < 0.05], respectively). The autoregulation was briefly impaired on the contralateral side during the infusion. A dose-dependent effect of CBF increments on favorable outcome was seen on Xe-CT scans (mRS Score 1-3, odds ratio 1.27 per 1 ml/100 g tissue x min, p = 0.045).

CONCLUSIONS

Bolus systemic hypertonic saline therapy may be used for reversal of cerebral ischemia to normal perfusion in patients with poor-grade SAH.

Anaesthetic considerations for interventional neuroradiology

In the past decade, the neuroradiological diagnosis and treatment of cerebrovascular diseases has undergone significant advances. With the introduction of varying diagnostic and interventional neuroradiological techniques and advances in the materials used for endovascular treatment, increasingly complex diagnostic and therapeutic neuroradiological procedures are being performed on extremely sick patients. As the interventional neuroradiology field expands, the neuroanaesthetist will become more involved in management of patients undergoing neuroradiological procedures. This produces challenges for the neuroanaesthetist, and understanding the anaesthetic implications of the current developments in neuroradiology is important in the management of these patients. This review provides an overview of diagnostic and therapeutic neuroradiological procedures, with special reference interventional neuroradiology, and the anaesthetic management of patients undergoing these procedures.

A new method for superselective middle cerebral artery infusion in the rat

OBJECT

Selective intraarterial drug delivery is used to achieve enhanced local uptake with reduced systemic side effects. In the present paper the authors describe and characterize a new microcatheter-based model of superselective perfusion of the middle cerebral artery (MCA) in rats combined with blockade of blood flow through the MCA.

METHODS

Selectivity of administration was shown by infusion of Evans blue which diffusely stained the MCA territory, indicating an increased permeability of the blood-brain barrier during the blockade of blood flow to the MCA. Perfusion of autologous blood through the microcatheter resulted in a flow rate-related increase in the cerebral blood flow measured by laser Doppler flowmetry. Similarly, infusion of an artificial O2 carrier, Oxycyte, was accompanied by an increase in tissue oxygenation as measured using a Licox sensor. Blockade of blood flow to the MCA with the new microcatheter for an extended period of time resulted in the development of ischemia, which was comparable to that induced by intravascular occlusion using a silicone-coated thread. In a 24-hour MCA occlusion model, selective administration of a low dose of MK-801 (0.3 mg/kg body weight) resulted in a significantly smaller infarct volume than systemic application (339 +/- 53 mm(3) compared with 508 +/- 26 mm(3), p < 0.001).

CONCLUSIONS

This new model of superselective MCA infusion is a valuable tool for investigating the effect of selective delivery and enhanced drug uptake into cerebral ischemic tissue. Without constant blockade of blood flow through the MCA it may also be useful for enhanced drug uptake, gene transfer, or application of stem cells in other neuropathological conditions.

Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage

Vasospasm is one of the leading causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH). Radiographic vasospasm usually develops between 5 and 15 days after the initial hemorrhage, and is associated with clinically apparent delayed ischemic neurological deficits (DID) in one-third of patients. The pathophysiology of this reversible vasculopathy is not fully understood but appears to involve structural changes and biochemical alterations at the levels of the vascular endothelium and smooth muscle cells. Blood in the subarachnoid space is believed to trigger these changes. In addition, cerebral perfusion may be concurrently impaired by hypovolemia and impaired cerebral autoregulatory function. The combined effects of these processes can lead to reduction in cerebral blood flow so severe as to cause ischemia leading to infarction. Diagnosis is made by some combination of clinical, cerebral angiographic, and transcranial doppler ultrasonographic factors. Nimodipine, a calcium channel antagonist, is so far the only available therapy with proven benefit for reducing the impact of DID. Aggressive therapy combining hemodynamic augmentation, transluminal balloon angioplasty, and intra-arterial infusion of vasodilator drugs is, to varying degrees, usually implemented. A panoply of drugs, with different mechanisms of action, has been studied in SAH related vasospasm. Currently, the most promising are magnesium sulfate, 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, nitric oxide donors and endothelin-1 antagonists. This paper reviews established and emerging therapies for vasospasm.

Endovascular Management of Cerebral Vasospasm

CEREBRAL VASOSPASM REMAINS a leading cause of death and disability in patients with ruptured cerebral aneurysms. The development of endovascular intervention in the past two decades has shown promising results in the treatment of vasospasm. Endovascular techniques that have been used in humans include intra-arterial infusion of vasorelaxants and direct mechanical dilation with transluminal balloon angioplasty. This article reviews the current indications and role of endovascular therapy in the management of cerebral vasospasm, its clinical significance, and potential future therapies.

Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage

Cerebral vasospasm remains a major source of morbidity and death in patients with aneurysmal subarachnoid hemorrhage (SAH). When vasospasm becomes refractory to maximal medical management consisting of induced hypertension and hypervolemia and administration of calcium channel antagonists, endovascular therapies should be considered. The primary goal of endovascular treatment is to increase cerebral blood flow to prevent cerebral infarction. Two of the more frequently studied endovascular treatments are transluminal balloon angioplasty and intraarterial papaverine infusion. These two have been used either alone or in combination for the treatment of vasospasm. Other pharmacological vasodilating agents currently being investigated are intraarterial nimodipine, nicardipine, verapamil, and milrinone. Newer intraarterial agents, such as fasudil and colforsin daropate, have also been investigated. In this article the authors review the current options in terms of endovascular therapies for treatment of cerebral vasospasm. The mechanism of action, technique of administration, clinical effect and outcomes, and complications of each modality are discussed.

Intra-arterial papaverine used to treat cerebral vasospasm reduces brain oxygen

INTRODUCTION

Intra-arterial papaverine (IAP) is used to treat symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH). IAP, however, can increase intracranial pressure (ICP). In this study we examined whether IAP alters brain oxygen (BtO2).

METHODS

Poor clinical grade (Hunt & Hess IV or V) SAH patients who underwent continuous ICP and BtO2 monitoring during IAP infusion for symptomatic cerebral vasospasm were evaluated as part of a prospective observational study.

RESULTS

Data are available for five patients (median age 58) who received IAP for cerebral vasospasm 4 to 7 days after SAH. In each patient, angiographic vasospasm was improved on postinfusion angiogram. Mean ICP before IAP was 23.04 +/- 1.18 mmHg; it increased immediately after IAP infusion and remained elevated (29.89 +/- 1.18 mmHg; p < 0.05) during IAP and for approximately 10 minutes after IAP ended. Baseline mean arterial pressure (MAP) was 110.55 +/- 1.36 mmHg. During IAP treatment MAP remained stable (110.90 +/- 2.00 mmHg; p = 0.31). Mean BtO2 before IAP was 32.99 +/- 1.45 mmHg. There was a significant BtO2 decrease in all patients during IAP to a mean of 22.96 +/- 2.9 mmHg (p < 0.05). BtO2 returned to baseline within 10 minutes after IAP ended. There was a modest relationship between the ICP increase and BtO2 decrease (R2 = 0.526).

CONCLUSION

IAP infusion to treat cerebral vasospasm following SAH can increase ICP and reduce BtO2. The IAP-induced reduction in BtO2 may help explain why IAP, although it reverses arterial narrowing, does not improve patient outcome.

Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: An Overview of Pharmacologic Management

Cerebral vasospasm remains one of the leading causes of mortality in patients who experience a subarachnoid hemorrhage but survive the initial 24 hours. Vasospasm generally occurs 3-4 days after the initial subarachnoid hemorrhage and peaks at 5-7 days. The pathophysiology of vasospasm is poorly understood, which directly contributes to the inconsistency of management and creates a formidable challenge in clinical practice. Traditionally, hemodilution, hypervolemia, and induced hypertension (so-called triple H therapy); calcium channel blockers; and endovascular therapy have been used as either prophylactic therapy or treatment. However, management of vasospasm varies among physicians and institutions mainly because of a lack of large clinical trials and inconsistent results. Practice has been based primarily on case reports and the preference of each practitioner. Several experimental therapies have been explored; however, large, prospective, randomized controlled trials are needed to elucidate the role of these therapies.

Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine

Cerebral vasospasm is still one of the leading causes of morbidity and mortality from subarachnoid hemorrhage. Vasospasm refractory to medical management can be treated with endovascular therapies, such as transluminal balloon angioplasty or infusion of intra-arterial vasodilating agents. In our review of clinical series reported in the English language literature, transluminal balloon angioplasty produced clinical improvement in 62% of patients, significantly improved mean transcranial Doppler (TCD) velocities(P <.05), significantly improved cerebral blood flow (CBF) in 85% of patients as studied by (133)Xenon techniques and serial single photon emission computerized tomography,and was associated with 5.0% complications and 1.1% vessel rupture. Intra-arterial papaverine therapy produced clinical improvement in 43% of patients but only transiently,requiring multiple treatment sessions (1.7 treatments per patient); significantly improved mean TCD velocities (P <.01) but only for less than 48 hours; improved CBF in 60% of patients but only for less than 12 hours; and was associated with increases in intracranial pressure and 9.9% complications. Intra-arterial nicardipine therapy produced clinical improvement in 42% of patients, significantly improved mean TCD velocities (P <.001) for 4 days, and was associated with no complications in our small series. We have adopted a treatment protocol at our institution of transluminal balloon angioplasty and intra-arterial nicardipine therapy as the endovascular treatments for medically refractory cerebral vasospasm.

Signaling mechanisms in cerebral vasospasm

The elusive nature of events that sustain cerebral vasospasm after subarachnoid hemorrhage resulting from a ruptured aneurysm presents major challenges in designing effective therapies for this frequently devastating condition. Protracted cerebral artery constriction entails several dynamic components in intracellular signaling events initiated by endothelial factors, products of hemolysate, and numerous kinases, as well as increased intracellular Ca(2+). The rationale for potential treatment modalities and their efficacy are discussed in this brief review.

Assessment of changes in cerebral circulation time due to vasospasm in a specific arterial territory: effect of angioplasty

This study demonstrates that in experienced hands, intracranial angioplasty is a feasible and safe option in a selected group of patients with severe (>50% stenosis) symptomatic vasospasm following subarachnoid hemorrhage. Cerebral circulation time is a surrogate parameter closely linked to cerebral perfusion. The study presented shows that not only stenosis but also changes in circulation time are obtained by angioplasty. Twenty angioplasties of one or two vessel segments were performed over 2 years in 18 consecutive patients with posthemorrhagic vasospasm fulfilling criteria for invasive treatment. In all patients, degree of stenosis and circulation time could be reduced by angioplasty. Clinical results were ranked according to Glasgow Outcome Scale. Imaging after 15/20 angioplasties showed no additional infarction. In 4/20 cases, CT showed demarcation of infarction after angioplasty. In 1/20 cases of posterior circulation angioplasty, CT is not sensitive enough to exclude smaller infarctions. Imaging and clinical outcome reveal a definite benefit.

Treatment of Cerebral Vasospasm with Intra-arterial Fasudil Hydrochloride

OBJECTIVE

Symptomatic cerebral vasospasm is a major cause of disability and death in patients with aneurysmal subarachnoid hemorrhage. The purpose of this study was to determine the efficacy of intra-arterial infusion (IAF) of fasudil hydrochloride for symptomatic vasospasm in terms of neurological improvement and the angiographic features of cerebral vessels.

METHODS

A consecutive series of 23 patients underwent IAF therapy for the treatment of symptomatic vasospasm after subarachnoid hemorrhage. Angiographic vasospasm was assessed before and after the IAF treatment. Immediate clinical effect was assessed within 24 hours after the IAF treatment, and the Glasgow Outcome Scale was used to evaluate late clinical outcome at 3 months after the onset.

RESULTS

IAF treatment was performed on 34 occasions for 23 patients (16 women, 7 men). Angiographic improvement was observed on all occasions (100%), and immediate clinical improvement was observed on 15 occasions (44.1%). At 3-month follow-up, 15 patients (65.2%) showed good recovery or moderate disability on the Glasgow Outcome Scale.

CONCLUSION

IAF therapy was effective in dilating spastic arteries, and clinical improvement was observed in approximately half of the fasudil hydrochloride infusions. Our findings suggested that the IAF therapy was safe and effective for patients with symptomatic vasospasm after subarachnoid hemorrhage.

Endovascular treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage

Endovascular treatment by balloon angioplasty or intra-arterial papaverine infusion has been established as a valuable treatment option in patients with cerebral vasospasm refractory to maximal medical therapy. A summary of the indications, applications and limitations is provided for microcatheter guided selective papaverine infusion and transluminal balloon angioplasty in patients who sustain cerebral vasospasm following subarachnoid haemorrhage. Structured neuro-intensive and endovascular treatment of imminent vasospasm integrate papaverine administration and balloon angioplasty as complimentary rather than alternative techniques.