Artikel
Refractory vasospasm after SAH – A prospective evaluation study of endovascular rescue therapies (ERT) using multimodal, continuous event neuromonitoring
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Veröffentlicht: | 8. Juni 2016 |
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Gliederung
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Objective: Critical hypoperfusion and consecutive metabolic derangement are frequently encountered in the context of severe vasospasm refractory to conservative treatment. This cerebral compromise can be detected reliably using continuous neuromonitoring (ptiO2, microdialysis). Endovascular rescue therapies (ERT) such as transluminal ballon angioplasty (TBA) for localized proximal vessel narrowing and continuous intraarterial lysis (IAL) for peripheral vasoconstriction have proven beneficial in selected cases. However, these treatment approaches are measures of last resort and quantitative results to document the efficacy of these ERT events regarding cerebral oxygenation and local and systemic metabolism are largely lacking and are the purpose of this prospective study.
Method: In order to detect cerebral compromise in a timely fashion, patients with aneurysmal SAH received invasive neuromonitoring including a ptiO2-measuring probe (Raumedic) and an intraparenchymal microdialysis catheter (µdialsyis) within the aneurysm-carrying vascular territory in accordance with our local standard operating procedure. ERT (TBA and/or IAL) were considered in cases of clinically relevant vasospasm refractory to conservative treatment alone (oral nimodipin, induced hypertension). For this analysis, particular emphasis was put on the development of oxygen saturation and cerebral and systemic metabolism before and after events of ERT.
Results: Since introduction of our neuromonitoring setup 14 months ago, we were able to record a total of 23 events in 11 patients where ballon dilatation (TBA=ERT 1; n=8), continuous intraarterial nimodipin infusion (IAL=ERT 2; n=11) or a combination of the two (TBA+IAL=ERT 3; n=4) were performed. Average cerebral ptiO2 was 9.4 ± 11mmHg before and 52.5 ± 23.2mmHg after ERT (p<0.001), with a lactate-pyruvate ratio (LPR) decreasing from 154.8 ± 119.1 before to 27.9 ± 10.7 after intervention (p<0.01). Comparable improvement was observed for each type of intervention (ERT 1, 2 or 3), with the exception of an absence of LPR improvement after TBA only (ERT 1). No significant alterations in systemic metabolism could be detected after ERT.
Conclusions: Multimodal, continuous event neuromonitoring is able to quantify treatment efficacy in challenging cerebrovascular cases such as SAH-related vasospasm. Our preliminary results support the use of ERT in selected cases of refractory vasospasm, as documented by improvement in both cerebral oxygenation and metabolism.