Should endovascular therapy for cerebral vasospasm coincide with hypervolemic-hypertensive therapy (HT) in aneurysmal subarachnoid hemorrhage (SAH)?

Introduction

In patients suffering from SAH, cerebral vasospasm is a major cause of morbidity and mortality from multifocal cerebral infaretion. Hypervolemic-hypertensive therapy is considered the cornerstone of the medical management and generally the first line approach. The therapeutic role of intra-arterial infusion of papaverine and balloon angioplasty has been established as an alternative therapy. The timing of neuroradiological intervention is unknown.

Methods

We retrospectively analyzed the charts of 537 patients with SAH, admitted in our institution between January 1987–December 1997. Of those, 156 (29%) received HT therapy, for clinically neurologic deficits attributable to cerebral vasospasm, after surgical aneurysm repair. Symptomatic vasospasm was defined as decrease in the level of consciousness or the appearance of new focal neurologic signs. Clinical and angiographic improvement, after HT alone, or in combination with neuroradiological intervention was studied.

Results

Of the 156 patients, 92 (58%) showed neurologic improvement with HT alone. Of the remaining 64 patients (42%), 37 (57%) underwent intra-arterial papaverine infusion and/or balloon angioplasty, as an adjunct treatment, after failure of medical therapy. 30 patients (81%) improved clinically, whereas 34 patients (89%) had angiographic amelioration alone. Twenty-seven patients (17%) failed medical therapy but did not receive intervention due to early death.

Conclusion

Our results indicate that endovascular therapy for symptomatic vasospasm contributes to significant clinical improvement. Medical therapy fails in almost half of the patients, of which a large proportion can additionally benefit from neuroradiological intervention. These results underscore the need for future studies on timing of both therapeutic modalities for cerebral vasospasm.