AUTHOR=Weiss Miriam , Conzen Catharina , Mueller Marguerite , Wiesmann Martin , Clusmann Hans , Albanna Walid , Schubert Gerrit Alexander 

TITLE=Endovascular Rescue Treatment for Delayed Cerebral Ischemia After Subarachnoid Hemorrhage Is Safe and Effective

JOURNAL=Frontiers in Neurology

VOLUME=10

YEAR=2019

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2019.00136

DOI=10.3389/fneur.2019.00136

ISSN=1664-2295

ABSTRACT=<p><bold>Background:</bold> The implementation of rescue efforts for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage remains largely empirical for a lack of supporting evidence, while the associated risk profile is also unclear.</p><p><bold>Objective:</bold> The present study evaluates the safety and efficacy of endovascular rescue treatment (ERT, continuous intraarterial nimodipine; IAN, transcutaneous balloon angioplasty, TBA).</p><p><bold>Methods:</bold> In this prospective observational study, we assessed periprocedural complications and side effects in context of ERT. We evaluated neurological status, multimodal neuromonitoring (p<sub>ti</sub>O<sub>2</sub>, lactate/pyruvate ratio, transcranial doppler), and cranial imaging (CTP, DSA). All parameters were included into multivariate analysis to determine predictors for the need of retreatment.</p><p><bold>Results:</bold> We included 33 consecutive patients with 54 ERT (IAN <italic>n</italic> = 35; TBA <italic>n</italic> = 13; TBA + IAN <italic>n</italic> = 6). We recorded no serious complications and initial improvement in all parameters (neurostatus 72.3% of patients; p<sub>ti</sub>O<sub>2</sub> 15.0 ± 11.7 to 25.8 ± 15.5 mmHg, <italic>p</italic> &lt; 0.0001; lactate/pyruvate ratio 46.3 ± 27.5 to 31.0 ± 9.7, <italic>p</italic> &lt;0.05; transcranial doppler 139.0 ± 46.3 to 98.9 ± 29.6 cm/s, <italic>p</italic> &lt; 0.05; CTP 81.6% of patients; DSA 93.1% of patients). Retreatment (<italic>n</italic> = 16, 48.5%) was independently associated with preinterventional p<sub>ti</sub>O<sub>2</sub> &lt; 5 mmHg (<italic>p</italic> &lt;0.01) and early (&lt;72 h) discontinuation of IAN treatment (<italic>p</italic> = 0.08). DCI related cerebral infarction was noted in <italic>n</italic> = 8 patients (24.2%). At 3 months after discharge, favorable outcome was noted for <italic>n</italic> = 11 (35.5%) patients.</p><p><bold>Conclusion:</bold> Provided a detailed decision tree, timely ERT can provide a relatively safe and effective treatment option in those highly-selected patients undergoing multimodality monitoring where conservative treatment options are exhausted. Continuous treatment in particular may be suitable to surpass sustained DCI and was associated with a low rate of DCI related infarction and comparably high percentage of good outcome.</p>