Figure - available from: Frontiers in Neurology
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Ten measured points. (A) Posterior-anterior projection of an internal carotid artery angiogram, C7 terminal segment of the internal carotid artery, nC7 narrowest point of C7, pM1 proximal horizontal segment of the middle cerebral artery, dM1 distal horizontal segment of the middle cerebral artery, M2 insular segment of the middle cerebral artery, pA1 proximal pre-communication segment of the anterior cerebral artery, dA1 distal pre-communication segment of the anterior cerebral artery, A2 post-communicating segment of the anterior cerebral artery. (B) Lateral projection of an internal carotid artery angiogram, C5 clinoid segment of the internal carotid artery, C6 ophthalmic segment of the internal carotid artery. In lateral projection: C5: 2 mm proximal to the origin of the ophthalmic artery and C6: at the origin of the ophthalmic artery. In posterior-anterior projection: C7: 2 mm proximal to the carotid T, nC7: the narrowest location in vasospastic arteries of C7 segments, pM1: 2 mm distal to carotid T, dM1: 2 mm proximal to middle cerebral artery bifurcation, M2: 4 mm distal to the M1/M2 transition, pA1: 2 mm distal to carotid T, dA1: 2 mm proximal to change of course and A2: 2 mm distal to change of course.
Source publication
Background
Cerebral vasospasm (CVS) continues to account for high morbidity and mortality in patients surviving the initial aneurysmal subarachnoid hemorrhage (SAH). Nimodipine is the only drug known to reduce delayed cerebral ischemia (DCI), but it is believed not to affect large vessel CVS. Milrinone has emerged as a promising option. Our retrosp...
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Citations
... To the best of our knowledge, there exist no clinical studies assessing the prophylactic properties of intra-arterial spasmolysis. This could be explained by the major drawback of vasopressor dependency when intra-arterial vasodilatory agents such as nimodipine or milrinone are used [99]. A pilot trial of prophylactic balloon angioplasty, with presumably rupture of the tunica medial of arterial vessels, disabling arterial constriction, demonstrated promising results [100]. ...
The 2023 International Subarachnoid Hemorrhage Conference identified a need to provide an up-to-date review on prevention methods for delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage and highlight areas for future research. A PubMed search was conducted for key factors contributing to development of delayed cerebral ischemia: anesthetics, antithrombotics, CSF diversion, and hemodynamic and endovascular management. Over 100 published articles were analyzed. It was found that there is still a need for prospective studies analyzing the best methods for anesthetics and antithrombotics, though inhaled anesthetics and antiplatelets were found to have some advantages. Lumbar drains should increasingly be considered the first line of CSF diversion when applicable. Finally, maintenance euvolemia before and during vasospasm is recommended as there is no evidence supporting prophylactic spasmolysis or angioplasty. There is accumulating observational evidence, however, that intra-arterial spasmolysis with refractory DCI might be beneficial in patients not responding to induced hypertension.
Background:
Evaluation of endovascular therapies for cerebral vasospasm (CVS) documented in the DeGIR registry from 2018-2021 to analyse the current clinical care situation in Germany.
Methods:
Retrospective analysis of the clinical and procedural data on endovascular spasm therapies (EST) documented anonymously in the DeGIR registry. We analysed: pre-interventional findings of CTP and consciousness; radiation dose applied, interventional-technical parameters (local medication, devices, angiographic result), post-interventional symptoms, complications and mortality.
Results:
3584 patients received a total of 7628 EST (median age/patient: 53 [range: 13-100, IQR: 44-60], 68.2 % women) in 91 (2018), 92 (2019), 100 (2020) and 98 (2021) centres; 5388 (70.6 %) anterior circulation and 378 (5 %) posterior circulation (both involved in 1862 cases [24.4 %]). EST was performed once in 2125 cases (27.9 %), with a mean of 2.1 EST/patient. In 7476 times, purely medicated EST were carried out (nimodipine: 6835, papaverine: 401, nitroglycerin: 62, other drug not specified: 239; combinations: 90). Microcatheter infusions were documented in 1132 times (14.8 %). Balloon angioplasty (BA) (additional) was performed in 756 EST (9.9 %), other mechanical recanalisations in 154 cases (2 %) and stenting in 176 of the EST (2.3 %). The median dose area product during ET was 4069 cGycm² (drug: 4002/[+]BA: 8003 [p < 0.001]). At least 1 complication occurred in 95 of all procedures (1.2 %) (drug: 1.1 %/[+]BA: 4.2 % [p < 0.001]). Mortality associated with EST was 0.2 % (n = 18). After EST, overall improvement or elimination of CVS was found in 94.2 % of cases (drug: 93.8 %/[+]BA: 98.1 % [p < 0.001]). In a comparison of the locally applied drugs, papaverine eliminated CVS more frequently than nimodipine (p = 0.001).
Conclusion:
EST have a moderate radiation exposure and can be performed with few complications. Purely medicated EST are predominantly performed, especially with nimodipine. With (additional) BA, radiation exposure, complication rates and angiographic results are higher or better. When considering drug EST alone, there is evidence for an advantage of papaverine over nimodipine, but a different group size has to be taken into account. In the analysis of EST, the DeGIR registry data are suitable for answering more specific questions, especially due to the large number of cases; for this purpose, further subgroupings should be sought in the data documentation.
Key points:
· In Germany, there are currently no guidelines for the endovascular treatment of cerebral vasospasm following spontaneous subarachnoid hemorrhage.. · In addition to oral nimodipine administration endovascular therapy is used to treat cerebral vasospasm in most hospitals.. · This is the first systematic evaluation of nationwide registry data on endovascular treatment of cerebral vasopasm in Germany.. · This real-world data shows that endovascular treatment for cerebral vasospasm has a moderate radiation exposure and can be performed with few complications overall. With (additional) balloon angioplasty, radiation exposure, complication rates and angiographic therapy results are higher or better..
Citation format:
· Neumann A, Weber W, Küchler J et al. Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018-2021: an overview of the current care situation. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2102-0129.
