Safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment after subarachnoid hemorrhage

Balloon angioplasty is often performed for symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. Angioplasty of the anterior cerebral artery (ACA), however, is perceived to be a challenging endeavor and not routinely performed due to technical and safety concerns. Here, we evaluate the safety and efficacy of balloon angioplasty of the anterior cerebral artery for vasospasm treatment. Patients with vasospasm following subarachnoid hemorrhage who underwent balloon angioplasty at our institution between 2011 and 2016 were retrospectively reviewed. All ACA angioplasty segments were analyzed for pre- and post-angioplasty radiographic measurements. The degree of vasospasm was categorized as mild (<25%), moderate (25–50%), or severe (>50%), and relative change in caliber was measured following treatment. Clinical outcomes following treatment were also assessed. Among 17 patients, 82 total vessel segments and 35 ACA segments were treated with balloon angioplasty. Following angioplasty, 94% of segments had increased caliber. Neurological improvement was noted in 75% of awake patients. There were no intra-procedural complications, but two patients developed ACA territory infarction, despite angioplasty treatment. We demonstrate that balloon angioplasty of the ACA for vasospasm treatment is safe and effective. Thus, ACA angioplasty should be considered to treat vasospasm in symptomatic patients recalcitrant to vasodilation infusion therapy.

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THE IMPACT OF BALLOON ANGIOPLASTY ON THE EVOLUTION OF VASOSPASM-RELATED INFARCTION AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000311351.32904.8b ◽

2008 ◽

Vol 62 (3) ◽

pp. 610-617 ◽

Cited By ~ 47

Author(s):

Leonie Jestaedt ◽

Mirko Pham ◽

Andreas J. Bartsch ◽

Ekkehard Kunze ◽

Klaus Roosen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Balloon Angioplasty ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Fisher Exact Test ◽

Computed Tomographic ◽

Fisher Grade ◽

The Impact

Abstract OBJECTIVE Vasospasm of the cerebral vessels remains a major source for morbidity and mortality after aneurysmal subarachnoid hemorrhage. The purpose of this study was to evaluate the frequency of infarction after transluminal balloon angioplasty (TBA) in patients with severe subarachnoid hemorrhage-related vasospasm. METHODS We studied 38 patients (median Hunt and Hess Grade II and median Fisher Grade 4) with angiographically confirmed severe vasospasm (>70% vessel narrowing). A total of 118 vessels with severe vasospasm in the anterior circulation were analyzed. Only the middle cerebral artery, including the terminal internal carotid artery, was treated with TBA (n = 57 vessel segments), whereas the anterior cerebral artery was not treated (n = 61 vessel segments). For both the treated and the untreated vessel territories, infarction on unenhanced computed tomographic scan was assessed as a marker for adverse outcome. RESULTS Infarction after TBA occurred in four middle cerebral artery territories (four out of 57 [7%]), whereas the infarction rate was 23 out of 61 (38%) in the anterior cerebral artery territories not subjected to TBA (P < 0.001, Fisher exact test). Three procedure-related complications occurred during TBA (dissection, n = 1; temporary vessel occlusions, n = 2). One of these remained asymptomatic, whereas this may have contributed to the development of infarction on follow-up computed tomographic scans in two cases. CONCLUSION In a population of patients with a high risk of infarction resulting from vasospasm after subarachnoid hemorrhage, the frequency of infarction in the distribution of vessels undergoing TBA amounts to 7% and is significantly lower than in vessels not undergoing TBA despite some risk inherent to the procedure.

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Aneurysmal subarachnoid hemorrhage in a patient with bilateral A1 fenestrations associated with an azygos anterior cerebral artery

Journal of Neurosurgery ◽

10.3171/jns.1996.84.4.0681 ◽

1996 ◽

Vol 84 (4) ◽

pp. 681-684 ◽

Cited By ~ 42

Author(s):

Robert M. Friedlander ◽

Christopher S. Ogilvy

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Vascular Anatomy ◽

Vascular Anomaly ◽

Rare Occurrence ◽

Content Type ◽

Proximal Anterior Cerebral Artery ◽

Current Article

✓ Fenestration of the proximal anterior cerebral artery (A1 segment) is a rare occurrence. This vascular anomaly is often associated with aneurysms and other abnormalities. The current article describes the case of a 33-year-old man who presented with a subarachnoid hemorrhage secondary to a ruptured aneurysm originating from the proximal end of an A1 fenestration. This patient also had a contralateral A1 fenestration as well as an azygos anterior cerebral artery. This is the first report of such an unusual vascular anatomy. The literature is reviewed and possible embryological mechanisms are discussed.

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Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013128 ◽

2017 ◽

Vol 10 (4) ◽

pp. 380-387 ◽

Cited By ~ 19

Author(s):

Anand Venkatraman ◽

Ayaz M Khawaja ◽

Sahil Gupta ◽

Shalaka Hardas ◽

John P Deveikis ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Outcome ◽

Patient Selection ◽

Balloon Angioplasty ◽

Medical Management ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Meta Analysis ◽

Neurological Improvement ◽

Good Outcome ◽

Neurological Response

ObjectiveThe efficacy of intra-arterial vasodilators (IADs) for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) remains debatable. The objective of this meta-analysis was to pool estimates of angiographic and neurological response, clinical outcome, and mortality following treatment of vasospasm with IADs.MethodsWe searched PubMed, Embase, Scopus, Clinicaltrials.gov, Cochrane database, and CINAHL in December 2015 and August 2016. Studies reporting angiographic and neurological response, clinical outcome, and mortality following IAD treatment of vasospasm in 10 or more adults with aSAH were included. All established IADs were allowed. Two authors independently selected studies and abstracted the data. Mean weighted probabilities (MWP) were calculated using random effects model.ResultsInclusion criteria were met by 55 studies (n=1571). MWP for immediate angiographic response to IAD treatment was 89% (95% CI 83% to 94%), post-IAD neurological improvement 57% (95% CI 49% to 65%), good outcome 66% (95% CI 60% to 71%), and mortality was 9% (95% CI 7% to 12%). After adjusting for publication bias, MWP for mortality was 5% (95% CI 4% to 7%). When transcranial Doppler (TCD) was used along with clinical deterioration for patient selection, rates of neurological response (64%) and good outcome (72%) were better. IADs were not superior to controls (balloon angioplasty or medical management).ConclusionIAD treatment leads to a robust angiographic response and fair (but lower) rates of neurological response and good clinical outcome. Mortality was lower than the average reported in the literature. Rates of neurological response and good outcome were better when TCD was used for patient selection. Carefully designed studies are needed to compare IADs against medical management and balloon angioplasty.

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Paradoxical aggravation of vasospasm with papaverine infusion following aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1996.84.4.0690 ◽

1996 ◽

Vol 84 (4) ◽

pp. 690-695 ◽

Cited By ~ 46

Author(s):

Brent L. Clyde ◽

Andrew D. Firlik ◽

Anthony M. Kaufmann ◽

MichaelP. Spearman ◽

Howard Yonas

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Artery Aneurysm ◽

Anterior Communicating Artery ◽

Left Middle Cerebral Artery ◽

Xenon Ct ◽

Content Type ◽

Symptomatic Vasospasm ◽

Fine Print

✓ Reports of intraarterial papaverine infusion as treatment for cerebral vasospasm are few and documented complications are uncommon. The authors report the case of a patient with paradoxical aggravation of cerebral arterial narrowing during selective intraarterial papaverine infusion intended to treat vasospasm following aneurysmal subarachnoid hemorrhage (SAH). A 48-year-old man presented to the authors' service with symptomatic vasospasm 10 days after experiencing an SAH. The ruptured anterior communicating artery aneurysm was surgically obliterated the following day, and thereafter maximum hypervolemic and hypertensive therapies were used. However, the patient remained lethargic, and a stable xenon—computerized tomography (CT) cerebral blood flow (CBF) study revealed CBF to be 15 cc/100 g/minute in the left anterior cerebral artery (ACA) and 25 cc/100 g/minute in the right ACA territories. Cerebral arteriography demonstrated diffuse severe left ACA and mild left middle cerebral artery (MCA) vasospasm. In response intraarterial papaverine was infused into the internal carotid artery just proximal to the ophthalmic artery. During the infusion the patient became aphasic and exhibited right hemiplegia. Arteriography performed immediately after the intraarterial papaverine infusion revealed diffuse exacerbation of vasospasm in the distal ACA and MCA territories. A repeat xenon—CT CBF study showed that CBF in the left ACA and the MCA had drastically decreased (2 cc/100 g/minute and 10 cc/100 g/minute, respectively). Despite aggressive management, infarction ultimately developed. This is the first clinical case to illustrate a paradoxical effect of intraarterial papaverine treatment for vasospasm following aneurysmal SAH. The possible mechanisms of this paradoxical response and potential therapeutic reactions are reviewed.

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Safety and Efficacy of Transluminal Balloon Angioplasty Using a Compliant Balloon for Severe Cerebral Vasospasm after an Aneurysmal Subarachnoid Hemorrhage

Journal of Korean Neurosurgical Society ◽

10.3340/jkns.2011.49.3.157 ◽

2011 ◽

Vol 49 (3) ◽

pp. 157 ◽

Cited By ~ 4

Author(s):

Beom Jin Choi ◽

Tae Hong Lee ◽

Jae Il Lee ◽

Jun Kyeung Ko ◽

Hwa Seung Park ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

Balloon Angioplasty ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Safety And Efficacy

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Safety and efficacy of transluminal balloon angioplasty in the prevention of vasospasm in patients with Fisher Grade 3 subarachnoid hemorrhage: a pilot study

Neurosurgical FOCUS ◽

10.3171/foc.1998.5.4.8 ◽

1998 ◽

Vol 5 (4) ◽

pp. E7 ◽

Cited By ~ 5

Author(s):

J. Paul Muizelaar ◽

Marike Zwienenberg ◽

Nancy A. Mini ◽

Stephen T. Hecht

Keyword(s):

Subarachnoid Hemorrhage ◽

Pilot Study ◽

Balloon Angioplasty ◽

Time Window ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Randomized Study ◽

Pilot Trial ◽

Safety And Efficacy ◽

Fisher Grade ◽

Grade 3

Recent advances in neuroradiology have made it possible to dilate human cerebral arteries that show vasospasm following aneurysmal subarachnoid hemorrhage (SAH), but the time window is short and the success rate for reversal of delayed ischemic neurological deficit (DIND) varies between 31% and 77%. In a canine model of vasospasm, transluminal balloon angioplasty (TBA) performed on Day 0 (the day of aneurysm rupture) has been shown to completely prevent the development of angiographically demonstrated narrowing by Day 7; this effect is better than any pharmacological treatment for vasospasm thus far described. The authors conducted a pilot trial to assess the safety and efficacy of TBA performed within 3 days post-SAH. Twelve patients with a very high probability of developing vasospasm (Fisher Grade 3) were included. Target vessels for prophylactic TBA were the internal carotid artery, A1 segment, M1 segment, and P1 segment bilaterally, the basilar artery, and the vertebral artery. No patient developed DIND or more than mild vasospasm, according to transcranial Doppler criteria. At 3 months, seven patients made a good recovery, two patients were moderately disabled, and three patients died; one patient died because of a vessel rupture during TBA and two older patients died of medical complications associated with an already poor clinical condition at admission. Compared with the results of large series reported in literature of patients with aneurysmal SAH, the results of this pilot study indicate an extremely low incidence of vasospasm and DIND after patients underwent prophylactic TBA. A larger, randomized study, however, is required to determine whether prophylactic TBA is efficacious enough to justify the risks.

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Delayed Ischemic Deterioration in Patients with Early Aneurysm Operation and Intravenous Nimodipine

Neurosurgery ◽

10.1227/00006123-198602000-00005 ◽

1986 ◽

Vol 18 (2) ◽

pp. 146-150 ◽

Cited By ~ 68

Author(s):

Säveland Hans ◽

Ljunggren Bengt ◽

Brandt Lennart ◽

Messeter Kenneth

Keyword(s):

Cerebral Artery ◽

Critical Period ◽

Internal Carotid ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Neurological Recovery ◽

Consecutive Series ◽

Symptomatic Vasospasm ◽

Potential Risk Factors ◽

Mca Aneurysm

Abstract A consecutive series of 100 individuals with aneurysmal subarachnoid hemorrhage were subjected to early aneurysm operation followed by subsequent intravenous administration of the calcium antagonist nimodipine during the critical period for symptomatic vasospasm. A total of 85 patients were in Hunt and Hess neurological Grades I through III, and 15 were in Grade IV or V before operation. In 39 individuals the aneurysm was located in the anterior cerebral artery complex (ACA), in 29 it originated from the internal carotid artery complex (ICA), and in 32 individuals the ruptured aneurysm arose from the middle cerebral artery (MCA). Of the patients, 71% made a good neurological recovery: the morbidity was 22%, and the mortality was 7%. Of the Grade I-III patients, 79% made a good neurological recovery, and the mortality was 6%. Delayed ischemic cerebral deterioration with permanent dysfunction occurred in five patients, all with ruptured ACA ancurysms. No single patient in the ICA or MCA populations developed delayed ischemic deterioration with fixed neurological deficit despite the presence of several potential risk factors, especially among the MCA aneurysm patients.

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