Artikel
Hemodynamically non-relevant angiographic vasospasm after aneurysmal subarachnoid hemorrhage: To treat or not to treat?
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Veröffentlicht: | 8. Juni 2016 |
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Objective: Angiographic vasospasm detectable in digital subtraction angiography (DSA) is a common complication of aneurysmal subarachnoid hemorrhage (SAH). The need for invasive treatment of hemodynamic relevant angiographic vasospasm (HRAV) is doubtless, while the advisability of spasmolysis for hemodynamically non-relevant angiographic vasospasm (HNAV) is controversial. The aim of this study was to analyze the clinical impact of interventional management of angiographic vasospasm.
Method: Of 364 consecutive SAH patients treated at our institution between January 2008 and December 2014, 181 individuals (49.7%) who underwent repetitive DSA(s) during 3 weeks after SAH were retrospectively reviewed. All cases with angiographic vasospasm were dichotomized into HRAV and HNAV. Functional outcome at 6 months was assessed using Glasgow Outcome Scale (GOS), where GOS=4-5 was defined as favorable outcome. Computed tomography scans were reviewed with regard to the occurrence of delayed cerebral ischemia (DCI).
Results: 90 patients (24.7%) underwent repetitive DSA suspected for cerebral vasospasm. In the remaining cases (n=91), repetitive DSA was performed due to other reasons (clipping control and/or treatment of other aneurysm(s)). In 72 patients (19.8%), HRAV was identified and (repetitively) treated during DSA. In 17 of 90 vasospasm-indicated DSAs (18.9%) and in 15 cases with repetitive DSA due to not-vasospasm-related reasons (16.5%), HNAV was visualized. Based upon individual judgment of neuroradiologists, 6 patients received and 26 did not receive intra-arterial nimodipine. Functional outcome of HNAV-patients undergoing spasmolysis was better, compared with HNAV-patients without spasmolysis (favorable outcome in 66.7% versus 56%, in-hospital mortality in 0% versus 15.4%, DCI in 33.3% versus 57.7% respectively). However, due to the small size of compared sub-cohorts, the difference was not statistically significant in bivariate correlations (p>0.05). Overall, clinical outcome of HNAV-patients was significantly poorer (p=0.0419, regardless the clinical evidence of vasospasm) than in individuals without any vasospasm on DSA.
Conclusions: Although often neglected, HNAV significantly worsens the functional outcome of SAH patients. Our data show the tendency towards outcome improvement of SAH patients with HNAV in those rare cases when prophylactic spasmolysis was performed. In order to confirm the advantages of prophylactic spasmolysis, further analysis with the inclusion of more patients is mandatory.