Angiographic response to endovascular treatment of post-hemorrhage cerebral vasospasm is not associated with clinical outcome

Abstract

Introduction

Post-hemorrhagic cerebral vasospasm (PHCV) in aneurysmal subarachnoid hemorrhage (aSAH) often requires endovascular intervention with either intra-arterial (IA) vasodilator therapy or percutaneous transluminal balloon angioplasty (PTA). This study aimed to evaluate the angiographic efficacy of endovascular treatments with clinical outcomes.

Methods

We retrospectively reviewed patients (≥18 years) who underwent IA vasodilator therapy or PTA for PHCV following aSAH at our institution from 2007 to 2023. Patients were stratified into “good” and “poor” outcome cohorts based on a 6-month modified Rankin Scale > 2. Identifiable risk factors were assessed using univariate and multivariate analyses. We compared angiographic changes in vessel diameter, cerebral circulation time (CCT), and retreatment rates between (1) PTA plus IA vasodilator sessions vs. IA-only sessions, and (2) verapamil-only vs. verapamil plus another agent. The statistically significant variables were used to create a scoring model to predict poor outcome.

Results

Eighty-three patients (mean age 52 years, 66 % female) with 246 treated vessels met inclusion criteria. IA vasodilators alone were used in 220 vessels, and PTA plus IA vasodilators were used in 26 vessels. 65 % of patients had a poor 6-month outcome. Male sex (p = 0.016), Black race (p = 0.030), hypertension (p = 0.015), earlier vasospasm onset (p = 0.016), and longer initial pre-treatment CCT (p = 0.033) were independently associated with poor outcomes. Vasospasm symptom of headaches alone (p = 0.044) was protective. PTA plus IA vasodilators more effectively increased the M1 diameter than IA vasodilators alone but CCT reductions were the same. Improvement in angiographic parameters was not associated with improved clinical outcome. Verapamil-only had the same angiographic and clinical outcomes compared to Verapamil plus another agent. The scoring model used 6-variables with an AUC = 0.746 to predict clinical outcomes.

Conclusions

In this single-center retrospective study of PHCV, despite angiographic improvements with endovascular therapy, there was no associated improvement in clinical outcomes.