Clinical, Angiographic, and Sonographic Findings After Structured Treatment of Cerebral Vasospasm and Their Relation to Final Outcomes

Summary  Objective. To report the early clinical results, quantitative angiographic and sonographic findings, and final outcome in patients with symptomatic vasospasm who had undergone surgical occlusion of the aneurysm and a structured protocol including aggressive intensive care management, endovascular procedures (EP), and barbiturate coma (BC).  Results. Thirty consecutive patients (19 women, 11 men, age: 51±8 years) underwent 38 EP for the treatment of 81 vascular territories (15 balloon dilatations and 66 papaverine infusions). Overall angiographic vasospasm in the intradural ICA improved significantly from 44. 7±19.8% to 16.5±16%, in the MCA from 44.2±14.7% to 14.4±14%, and in the ACA from 38.7±18.6% to 13.3±12%. Mean flow velocities (Vm) in the MCA and ACA decreased significantly from 135±48 cm/sec to 87±32 cm/sec and from 110±36 cm/sec to 84±30 cm/sec, respectively. No significant Vm improvement in the ICA could be demonstrated. Six patients (20%) developed intractable vasospasm after repeated EP and five patients underwent BC. The correlation coefficient between percentage of angiographic vasospasm and Vm increase was −0.19 (p=NS) for the ICA, 0.2 (p<0.001) for the MCA, and 0.3 (p<0.05) for the ACA. Correlation coefficient between percentages of angiographic and sonographic improvement was −0.12 (p=NS) for the ICA, 0.42 (p<0.001), and 0.1 (p<0.05) for the ACA. Early clinical improvement after EP was observed in 73% of patients and was significantly associated with favourable outcome (GOS 4–5). Sixteen patients (53%) had a GOS 5, six patients (20%) a GOS 4, six patients (20%) a GOS 3, and two patients (6.6%) died as consequence of devastating vasospasm.  Conclusions. Changes in vessel diameter and increases of Vm during vasospasm correlate weakly. In spite of the fact that significant differences in vessel diameter and Vm were demonstrated after treatment, a moderately good correlation between percentages of angiographic and Vm improvement was observed only in the M1 segments. In our experience, a reduction of mortality and disabilities can be achieved with a maximal structured treatment of vasospasm. Early clinical improvement after endovascular treatment is strongly associated with favourable outcome, nevertheless, cost-benefit and controlled trials are necessary to evaluate these techniques.