The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage

OBJECTIVE: Cerebral angioplasty is being increasingly used for symptomatic vasospasm secondary to subarachnoid hemorrhage. We attempted to determine the safety and efficacy of angioplasty for refractory vasospasm. We also looked at the influence of timing of angioplasty on outcome. METHODS: We retrospectively studied patients with subarachnoid hemorrhage who underwent angioplasty in our institution to determine the safety and the success rate achieved with this procedure. The study period extended from August 1993 until February 1997. Clinical and radiological data were collected, with emphasis on clinical improvement after angioplasty and its relationship with timing of intervention. Thirty-one patients with 43 aneurysms and one case of arteriovenous malformations were included. Their ages varied between 28 and 68 years, with an average age of 44 years. Five patients were assigned Hunt and Hess Grade IV, 15 were assigned Grade III, 7 were assigned Grade II, and 4 were assigned Grade I. All patients except two underwent angioplasty after aneurysm clipping or coiling. RESULTS: Angioplasty was performed an average of 6.9 days after the occurrence of subarachnoid hemorrhage, with a range from 1 to 14 days. It was performed early (within 24 h) after refractory clinical deterioration in 21 patients. A total of 81 vessels were dilated. Three angioplasty-related complications occurred: two femoral hematomas and one retroperitoneal hematoma. Clinical improvement was dramatic after 12 procedures, moderate after 11 procedures, and minimal or nonexistent after 9 procedures. There was a clear tendency toward more significant improvement in patients with earlier angioplasty (<24 h from onset of neurological deficit) (P = 0.0038). At discharge, 8 patients had achieved good recoveries (Glasgow Outcome Scale score of 1), 11 had moderate disabilities (Glasgow Outcome Scale score of 2), and 10 had severe disabilities (Glasgow Outcome Scale score of 3). Two deaths were encountered, and they were unrelated to angioplasty. Follow-up was obtained for 27 patients: 25 had good outcomes, 1 was moderately disabled, and 1 died. There was no significant correlation between interval and outcome. CONCLUSION: Our results indicate that angioplasty is a safe and effective treatment for symptomatic vasospasm that is refractory to hyperdynamic hypervolemic therapy. When used early (<24 h), it leads to significant clinical improvement. However, the long-term outcome is good, even in cases of delayed angioplasty. The prevention of worsening of the cerebral ischemia and its extension to other territories may be the reason.