Aggressive endovascular procedure
Cerebral vasospasm remains a major cause of morbidity and mortality among patients after they survive initial SAH and undergo definitive aneurysm treatment. Of patients with aneurysmal SAH, 30–70% develop cerebral angiographic vasospasm, with death or permanent disability noted in 7–20%.[1, 6, 7] Younger age, poor presenting grade, and diffused subarachnoid clot are well-known risk factors for post-SAH vasospasm.[18, 2, 8] However, despite less favorable outcomes, patients with poor neurological status and even ischemic changes on CT scan, still appear to benefit from early endovascular therapy.[6, 8] Patients with poor consciousness status need not be excluded from this life-saving intervention. This is well demonstrated in our study of patients with significant vasospasm: the majority were of a younger age (mean age = 50 years), 68% presented with at least a Hunt–Hess grade of 3, and 70% had thick diffuse subarachnoid blood (Fisher grade > = 3). In our study, 70.8% of patients with a high clinical grade (Hunt–Hess grade 4–5) could still attain a favorable outcome (mRS < = 2); 60% (6/10) of patients with unconsciousness before angioplasty could regain consciousness and 40% recover to achieve an excellent clinical outcome. In these patients, the symptoms of vasospasm could not be detected easily and early. Therefore, early diagnosis by routine image study during the high-risk period of post-SAH vasospasm was necessary.
In the past, the endovascular approach was often required only in patients with symptoms that were refractory to medical management. However, no definite waiting time was suggested for “refractory.” In our study, 100% of angiographic and 94% of symptomatic vasospasms improved after angioplasty combined with balloon angioplasty and IA nimodipine, without any complications. These results compare favorably to those of other studies. In the recent literatures, the efficacy of mechanical balloon angioplasty was nearly 90 to 100%, associated clinical improvement rate of 60–75% and a complication rate of 5%.[8, 18, 17, 19, 20] For comatose and high clinical grading patients, the reports were rare and only 0 to 30% patients had good clinical result.[20, 8] Our results demonstrated that in patients with symptomatic or severe vasospasm, neurosurgeons and neurointerventionalists should treat the condition more aggressively and endovascular therapy should be performed as soon as possible.
Simple IA vasodilator therapy is also effective but often transient, time insufficient, and requires multiple treatment sessions. Balloon angioplasty is suitable in larger vessels and has been reported as a relatively safe, effective, and durable procedure.[21, 12] Therefore, we recommend a combined procedure of balloon angioplasty in major vessels and continuous nimodipine infusion, which was effective for distal and diffuse vasospasm during the procedure. In our study, only one patient (2%) required a secondary session of angioplasty treatment. However, because the target vessel was different, the durability of balloon angioplasty remained apparent.
Superiorities Of Scepter Xc Balloon For Angioplasty
The Scepter XC balloon had favorable performance in the treatment of cerebral vasospasm in all consecutive patients without procedure-related complications in our series. The Scepter XC balloon was extremely trackable, facilitated safe, and was able to navigate distally into the intracranial circulation (the A2 and M3 segments). The Scepter XC balloon accommodates a larger 0.014-inch microwire, which provides significant stability to the balloon during navigation of tortuous vessels and distal advancement.[13, 16] Furthermore, during the balloon inflation, the 0.014-inch microwire provided increased stability, which resulted in less slippage along the vessel wall relative to the single lumen balloons that have been used previously. Last, we can use a single balloon for multiple segments with repeated inflation and deflation without the need to replace the balloon.
Studies have reported a complication rate of 1–4%; such complications are arterial rupture, dissection, and thrombus formation during angioplasty for vasospasm.[10, 12] Theoretically, the improved stability of inflation and the extra-compliant characteristic should be protective against arterial injury and rupture. In our experience, during inflation, the extra-compliant design of the Scepter XC balloon tended to conform to the course of the vessel concurrent with radial expansion. The Scepter XC balloon was elliptically shaped at full inflation with two enhanced tips at both ends of the balloon. During inflation, the balloon gradually dilated from the central area and then bilaterally expanded evenly along the vessel wall (Fig. 2A, 2B, & Fig. 3A). This conformation to the native vessel shape reflects the extra soft nature of the balloon and, in our opinion, leads to a more controllable and gentler balloon inflation. When the operator observes the balloon gradually expand near the two end markers of the balloon, the procedure could be ceased and deflation should be initiated; this characteristic of Scepter XC could prevent over-inflation, which causes vessel rupture (Fig. 2C & Fig. 3B). Generally, it takes less than 10 seconds to deflate the fully-inflated balloon in the diseased segment. Careful planning prior to endovascular treatment can reduce procedure time and lead to maximal improvement of cerebral vasospasm.
Moreover, simultaneous IA administration of nimodipine or other calcium channel blockers through the double lumen balloon catheter can augment the results of cerebral angioplasty, especially at distal circulation.[12, 9] In our experience, after a full angioplasty session, both target vessels, which were treated by balloon angioplasty, and distal vasospasms, treated by nimodipine, were improved simultaneously (Fig. 2D & Fig. 3C). After the diameter of proximal vessels was regained, more cerebral blood flow and more vasodilator effects could reach distal regions and increase cerebral perfusion. That may be why the effect of angioplasty is so durable and the functional outcome is so remarkable.