Article
The impact of endovascular rescue therapies for refractory vasospasm on long-term functional outcome in patients with aneurysmal subarachnoid haemorrhage
Einfluss der endovaskulären Therapie auf das Langzeit-Outcome von Patienten mit aneurysmatischer Subarachnoidalblutung und refraktären Vasospasmus
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Published: | June 26, 2020 |
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Objective: Cerebral vasospasm (CV) represents one of multiple contributors to delayed cerebral ischemia (DCI) in patients with aneurysmal subarachnoid hemorrhage (aSAH). Especially, the management of CV refractory to medical treatment is a challenging task during the acute treatment of aSAH-patients. Endovascular rescue therapies (ERT) such as medical/mechanical dilation is performed in these patients with a decision-making on an individual base. The effective impact of these treatment options on the functional outcome of aSAH-patients is insufficiently evaluated. The aim of this study was to assess the impact of ERT on long-term functional outcome in aSAH-patients with refractory CV.
Methods: We performed a retrospective analysis of aSAH patients treated between 2008 and 2018. CV was considered refractory if it persisted despite of oral Nimodipine application and induced hypertension. The decision to perform ETR was made on an individual base according to the “tissue at risk” detection in computer tomography perfusion (CTP) and CV in computed tomography angiography (CTA) or digital subtraction angiography (DSA). The functional outcome was assessed according to the modified Rankin scale (mRS) at least 3 months after the ictus, whereas a mRS≤3 was considered a good outcome.
Results: A total of 375 patients were included. 321 patients (85.9%) were treated without ERT (group 1) and 54 patients (14.1%) with ERT (group 2). A good aSAH-grade (Hunt&Hess I-III) was found in 60.4% in group 1 compared to 67.1% in group 2. Delayed infarction occurred in 21% in group 1 compared to 40.7% in group 2 (Welch t-test, p=0.0073). A good clinical outcome had 47.6% in group 1 vs 63.63% in group 2 (Welch t-test, p=0.002).
The radiation exposure (RE) in patients with ERT was significantly higher compared to the patient group without ERT (Welch t-test, p=0.014).
Conclusion: Although, the rate of delayed infarction was significantly higher in the patient group with ETR, ETR resulted in a significantly better functional outcome compared to the patient group without ETR. Since ERT is associated with RE and other procedure-related complications selection criteria are essential in aSAH patients. A CTP-based identification of “tissue at risk” seems to be a reliable tool for patient selection.