The efficacy and safety of intraarterial rescue therapies for the management of refractory delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage
Amr Abdulazim (Mannheim), Neele Riemann (Mannheim), Hannah Roth (Mannheim), Marina Heilig (Mannheim), Fabian Wenz (Mannheim), Katharina Hackenberg (Mannheim), Eva Neumaier-Probst (Mannheim), Christoph Groden (Mannheim), Mervyn Vergouwen (Utrecht / NL), Gabriel Rinkel (Mannheim; Utrecht / NL), Nima Etminan (Mannheim)
The risk benefit ratio of intraarterial rescue therapy strategies for intractable delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (SAH) remains uncertain. We analysed the safety and efficacy of intraarterial rescue therapies.
A prospective cohort of 379 consecutive SAH patients admitted to our department between January 2016 and December 2022 was treated using a standardized, escalating treatment protocol in case of persistent clinical or radiological (CT perfusion impairment and/or severe angiographic vasospasm) features of DCI: 1) induced hypertension >180mmHg systolic, 2) twice solitary intraarterial nimodipine bolus applications during catheter angiography, 3) angiographic application of an intraarterial catheter for continuous nimodipine administration over 48 hours with CT Perfusion imaging in between each escalating step. Efficacy was evaluated by means of clinical (recovery of a neurological deficit) and/or radiological (resolution of a CT perfusion deficit) improvement after treatment. Safety was evaluated by means of treatment associated complications.
Of the 379 SAH patients, 126 received at least one intraarterial nimodipine bolus application and were included in this analysis. Clinical improvement occurred in 33 (26.2%) and radiological improvement in 42 (33.3%) patients. A second intraarterial nimodipine bolus was performed in 64 (51%) patients. Of those, 15 (23%) had clinical and 30 (47%) radiological improvement after the treatment. An intraarterial catheter for continuous nimodipine administration was used in 16 (25%) among those patients. Overall, a total of 43 patients received an intraarterial catheter for continuous nimodipine administration. Clinical and/or radiological improvement was notable in 25 (58%) patients whereas in 15 (34.9%) additional intraarterial treatments were given. The rate of unfavourable outcome in patients treated by means of an intraarterial catheter was 65.1%. The overall catheter-associated complication rate was 27.9%, mainly comprising of catheter dysfunction (33.3%), catheter-associated haemorrhages (16.7%), and catheter-associated infarctions (16.7%).
Intraarterial rescue therapy for intractable DCI is associated with clinical or radiological improvement in one out of 2 to 4 patients. This beneficial effect may be offset by treatment associated complications. Matched-pair analyses are warranted to further elucidate to what degree unfavourable outcome rates are affected.
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