Symptomatic Cerebral Vasospasm after Spontaneous Subarachnoid Hemorrhage: Comparison of Single and Multiple Intra-arterial Treatment with Respect to the Functional Outcome

Alexander Neumann; Claudia Ditz; Hannes Schacht; Linda Aulmann; Volker Martin Tronnier; Peter Schramm; Jan Nils Küchler

doi:10.1055/s-0039-1698434

Journal of Neurological Surgery Part A: Central European Neurosurgery, Table of Contents

J Neurol Surg A Cent Eur Neurosurg 2020; 81(03): 220-226
DOI: 10.1055/s-0039-1698434

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Symptomatic Cerebral Vasospasm after Spontaneous Subarachnoid Hemorrhage: Comparison of Single and Multiple Intra-arterial Treatment with Respect to the Functional Outcome

Alexander Neumann

¹Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck , Schleswig-Holstein, Germany

,

Claudia Ditz

²Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Schleswig-Holstein, Germany

,

Hannes Schacht

¹Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck , Schleswig-Holstein, Germany

,

Linda Aulmann

¹Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck , Schleswig-Holstein, Germany

,

Volker Martin Tronnier

²Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Schleswig-Holstein, Germany

,

Peter Schramm

¹Department of Neuroradiology, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck , Schleswig-Holstein, Germany

,

Jan Nils Küchler

²Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Schleswig-Holstein, Germany

› Author Affiliations

Abstract

Objective In cases of spontaneous subarachnoid hemorrhage (sSAH) and symptomatic cerebral vasospasm (sCVS), multiple intra-arterial treatments (IATs) can be potentially useful for the functional outcome, even if the prognosis is initially poor. But the actual influence of the number of IATs has yet to be clarified. We wanted to assess if there are differences in the functional outcome between patients with a singular IAT and multiple IATs for sCVS after sSAH.

Methods In a single-center study, 405 consecutive patients with nontraumatic SAH were analyzed retrospectively. A total of 126 developed sCVS, and 86 received IAT (32 singular and 54 multiple, i.e., more than one) with nimodipine with or without percutaneous transluminal angioplasty (PTA). Both groups were compared for demographic data, initial treatment (clipping or endovascular), and initial grading (World Federation of Neurosurgical Societies/Fisher classification, intraventricular hemorrhage, and intracerebral hemorrhage). The modified Rankin Scale (mRS) was used to assess functional outcome at the time of discharge and after 3 and 6 months. The development of CVS-associated infarction was assessed by computed tomography (CT). Categorical variables of the patient groups were analyzed in contingency tables using the Fisher exact test, chi-square test, and the Mann-Whitney U test. Statistical significance was accepted at p < 0.05.

Results Patient groups with singular and multiple IATs were comparable concerning demographic data and initial grading. At the end of follow-up after 6 months, both groups showed comparable functional outcomes. A favorable outcome (mRS: 0–3) was observed in 14 of 26 patients (53.9%) with a single IAT and for 29 of 49 patients (59.2%) with multiple IATs. An unfavorable outcome (mRS: 4–6) occurred in 12 of 26 patients (46.1%) with a single IAT and for 20 of 49 patients (40.8%) with multiple IATs (p = 0.420). In the group with a single IAT, 22 of 32 patients (68.8%) developed CVS-associated infarction; 32 of 54 patients (59.3%) showed brain infarcts after multiple IATs (p = 0.259).

Conclusion For patients with sCVS after sSAH, multiple IATs (nimodipine with or without additional PTA) can be applied safely because no significant differences in functional outcome were observed compared with a singular IAT. We conclude that patients should be treated repeatedly if vasospasm reoccurs.

Keywords

subarachnoid hemorrhage - cerebral vasospasm - nimodipine - endovascular treatment - delayed cerebral ischemia

Full Text

References

References
1 AlMatter M, Aguilar Péreza M, Bhogal P, Hellstern V, Ganslandt O, Henkes H. Results of interdisciplinary management of 693 patients with aneurysmal subarachnoid hemorrhage: clinical outcome and relevant prognostic factors. Clin Neurol Neurosurg 2018; 167: 106-111
2 Teasdale GM, Drake CG, Hunt W. , et al. A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry 1988; 51 (11) 1457
3 Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980; 6 (01) 1-9
4 Chotai S, Ahn SY, Moon HJ. , et al. Prediction of outcomes in young adults with aneurysmal subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 2013; 53 (03) 157-162
5 Inagawa T. Risk factors for cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a review of the literature. World Neurosurg 2016; 85: 56-76
6 Kanamaru K, Suzuki H, Taki W. Cerebral infarction after aneurysmal subarachnoid hemorrhage. Acta Neurochir Suppl (Wien) 2016; 121: 167-172
7 Fehnel CR, Gormley WB, Dasenbrock H. , et al. Advanced age and post-acute care outcomes after subarachnoid hemorrhage. J Am Heart Assoc 2017; 6 (10) e006696
8 Zanaty M, Nakagawa D, Starke RM. , et al. Intraventricular extension of an aneurysmal subarachnoid hemorrhage is an independent predictor of a worse functional outcome. Clin Neurol Neurosurg 2018; 170: 67-72
9 Darkwah Oppong M, Skowronek V, Pierscianek D. , et al. Aneurysmal intracerebral hematoma: risk factors and surgical treatment decisions. Clin Neurol Neurosurg 2018; 173: 1-7
10 Haegens NM, Gathier CS, Horn J, Coert BA, Verbaan D, van den Bergh WM. Induced hypertension in preventing cerebral infarction in delayed cerebral ischemia after subarachnoid hemorrhage. Stroke 2018; 49 (11) 2630-2636
11 Hänggi D, Turowski B, Beseoglu K, Yong M, Steiger HJ. Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid hemorrhage: influence on clinical course and cerebral perfusion. AJNR Am J Neuroradiol 2008; 29 (06) 1053-1060
12 Jestaedt L, Pham M, Bartsch AJ. , et al. The impact of balloon angioplasty on the evolution of vasospasm-related infarction after aneurysmal subarachnoid hemorrhage. Neurosurgery 2008; 62 (03) 610-617 ; discussion 610–617
13 Mortimer AM, Steinfort B, Faulder K. , et al. The detrimental clinical impact of severe angiographic vasospasm may be diminished by maximal medical therapy and intensive endovascular treatment. J Neurointerv Surg 2015; 7 (12) 881-887
14 Ditz C, Neumann A, Wojak J. , et al. Repeated endovascular treatments in patients with recurrent cerebral vasospasms after subarachnoid hemorrhage: a worthwhile strategy?. World Neurosurg 2018; 112: e791-e798
15 Jia L, Wang H, Gao Y, Liu H, Yu K. High incidence of adverse events during intra-hospital transport of critically ill patients and new related risk factors: a prospective, multicenter study in China. Crit Care 2016; 20: 12
16 Terry A, Zipfel G, Milner E. , et al. Safety and technical efficacy of over-the-wire balloons for the treatment of subarachnoid hemorrhage-induced cerebral vasospasm. Neurosurg Focus 2006; 21 (03) E14
17 Vergouwen MD, Vermeulen M, van Gijn J. , et al. Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group. Stroke 2010; 41 (10) 2391-2395
18 Connolly Jr ES, Rabinstein AA, Carhuapoma JR. , et al; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; 43 (06) 1711-1737
19 Abruzzo T, Moran C, Blackham KA. , et al. Invasive interventional management of post-hemorrhagic cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. J Neurointerv Surg 2012; 4 (03) 169-177
20 Hollingworth M, Chen PR, Goddard AJ, Coulthard A, Söderman M, Bulsara KR. Results of an international survey on the investigation and endovascular management of cerebral vasospasm and delayed cerebral ischemia. World Neurosurg 2015; 83 (06) 1120-1126.e1
21 Jones J, Sayre J, Chang R. , et al. Cerebral vasospasm patterns following aneurysmal subarachnoid hemorrhage: an angiographic study comparing coils with clips. J Neurointerv Surg 2015; 7 (11) 803-807
22 Molyneux A, Kerr R, Stratton I. , et al; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002; 360 (9342): 1267-1274
23 Shao B, Wang J, Chen Y. , et al. Clipping versus coiling for ruptured intracranial aneurysms: a meta-analysis of randomized controlled trials. World Neurosurg 2019; 127: e353-e365
24 Dorhout Mees SM, Kerr RS, Rinkel GJ, Algra A, Molyneux AJ. Occurrence and impact of delayed cerebral ischemia after coiling and after clipping in the International Subarachnoid Aneurysm Trial (ISAT). J Neurol 2012; 259 (04) 679-683
25 Teo M, Guilfoyle MR, Turner C, Kirkpatrick PJ. ; STASH Collaborators. What factors determine treatment outcome in aneurysmal subarachnoid hemorrhage in the modern era? a post hoc STASH analysis. World Neurosurg 2017; 105: 270-281
26 Boulouis G, Labeyrie MA, Raymond J. , et al. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Eur Radiol 2017; 27 (08) 3333-3342
27 Andereggen L, Beck J, Z'Graggen WJ. , et al. Feasibility and safety of repeat instant endovascular interventions in patients with refractory cerebral vasospasms. AJNR Am J Neuroradiol 2017; 38 (03) 561-567
28 Duman E, Karakoç F, Pinar HU, Dogan R, Fırat A, Yıldırım E. Higher dose intra-arterial milrinone and intra-arterial combined milrinone-nimodipine infusion as a rescue therapy for refractory cerebral vasospasm. Interv Neuroradiol 2017; 23 (06) 636-643
29 Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N. Continuous local intra-arterial nimodipine administration in severe symptomatic vasospasm after subarachnoid hemorrhage. Neurosurgery 2011; 68 (06) 1541-1547 ; discussion 1547