Diagnosis and treatment of subarachnoid hemorrhage-induced vasospasm

Introduction

Vasospasm occurs in up to 70% of subarachnoid hemorrhages (SAHs). Transcranial Doppler (TCD) and cerebral angiography (AGF) are used to monitor and guide its treatment; however, no systematic approach to interpret their values exists yet. The aim of our study was to evaluate the correspondence between sonographic and angiographic findings and the efficacy of the endovascular treatment.

Methods

One hundred and one patients were admitted to our neurological ICU with SAH from June 2006 to September 2008. All of them were examined with daily TCD. Mean flow velocity in the middle cerebral artery >200 cm/s or an increase >50 cm/s/day or a mean flow velocity in the other arteries more than two times the normal values were interpreted as indicative of severe vasospasm. If a second TCD showed high blood velocities, an AGF was performed. If the vasospasm was confirmed, the patient was considered eligible for endovascular treatment. Ten patients developed severe vasospasm and were analyzed in this study.

Results

All patients presented poor clinical condition at admission (Hunt Hess 4 ± 0.9, Fisher grade 3.7 ± 0.4). Sixty percent developed intracranial hypertension and 30% needed barbiturate coma and decompressive craniectomy. Severe vasospasm occurred 9 days after SAH (8.5 ± 4.4). In 100% there was correspondence between sonographic and angiographic diagnosis of vasospasm. Eighteen endovascular treatments were performed (70% either intra-arterial nimodipine or transluminal balloon angioplasty, 30% intra-arterial nimodipine). Angiographical and clinical improvement was obtained in 80% of endovascular procedures, the sonographical efficacy in 75% of them. Nine patients developed recurrent vasospasm after the endovascular therapy. Each patient received 1.8 ± 1.03 treatments. Two patients with refractory vasospasm died in the neurological ICU for intracranial hypertension; the other eight patients had good recovery at discharge (Glasgow coma scale 12 ± 2.3). At the 6-month follow-up all patients had a favorable Glasgow outcome score (3.9 ± 1.59).

Conclusion

Our study confirmed the excellent correlation between TCD and angiography in patients with middle cerebral artery flow velocity >200 cm/s. TCD can be considered a very useful bedside tool for early detection of vasospasm. The endovascular management of vasospasm appeared to be safe and effective. The efficacy of the association of pharmacological and mechanical approach in improving outcomes after SAH and in reducing the frequency of secondary neurologic deficits was demonstrated.