Institution of sustained endovascular treatment prior to clinical deterioration in patients with severe angiographic vasospasm: A retrospective observational study of clinico-radiological outcomes

SummarySevere angiographic vasospasm (aVSP) is a risk factor for infarction following subarachnoid haemorrhage and infarction is strongly associated with poor outcome. We present the clinico-radiological results of cohort with severe aVSP who underwent a program of angiographic surveillance and sustained endovascular treatment using multiple verapamil infusions and/or transluminal balloon angioplasty (TBA).MethodsThis was a dual-centre retrospective observational study. Angiographic screening for vasospasm was undertaken at days 5–7 post-ictus. Treatment was instituted principally on the basis of radiographic findings. The rate of infarction was evaluated on follow-up CT. Clinical outcome was assessed using the modified Rankin Scale (mRS).ResultsFifty-seven WFNS grades 1–5 patients were studied. The mean number of procedures/patient was 6, range 2–13. Mean verapamil dose administered to the ICA was 14 mg and VA was 12 mg. Thirty-one patients underwent TBA (52.6%). The rate of proximal vessel infarction was 3/45 (6.7%) for patients presenting < 72 hours. Rates of favourable outcome (mRS 0–2) were 16/19 (84.2%) for WFNS grades 1–2, 12/19 (63.2%) for grades 3–4 and 5/19 (26.3%) for grade 5 patients. Delayed presentation > 72 hours was the only factor on multivariate analysis to significantly predict aVSP-infarction [OR19.3 (3.2–116.6) P = 0.0012]. Large aVSP-infarction [OR19.0 (1.7–216.4) 0.0179] and poor WFNS grade [OR 6.6 (1.3–33.9) P = 0.0233] were significant predictors of poor outcome on multivariate analysis.ConclusionThis approach may result in low rates of aVSP-infarction and encouraging rates of favourable outcome when compared to literature benchmarks. Delayed presentation, however, predicts infarction and large infarct and poor initial grade significantly influence functional outcome.