Intracranial Stenting as a Bail-out Option for Posthemorrhagic Cerebral Vasospasm: A Single-Center Experience with Long-Term Follow-Up

Abstract

Background: Cerebral vasospasm is a leading cause of morbidity and mortality in patients after subarachnoid hemorrhage (SAH). Endovascular treatment, including intraarterial infusion of drugs with vasodilation effects, and balloon- and stentriever angioplasty, are helpful but can achieve only short-term effects in some patients. A need remains for long-lasting treatment of refractory recurrent vasospasm. We report our experience in stent implantation as a treatment for recurrent severe post-SAH vasospasm.Methods: A retrospective analysis of our institutional database of 883 patients with SAH, managed between January 2010 and December 2021, was performed. Six patients were identified as having received intracranial stenting in the context of post-SAH cerebral vasospasm. All patients were initially treated with intra-arterial infusion of nimodipine and/or milrinone. Self-expanding intracranial stents were implanted during endovascular aneurysm treatment to enable access despite impaired perfusion or as a bail-out strategy after failed intraarterial drug infusion or mechanical treatment. All stented patients received dual antiplatelet therapy (DAPT).Results: Nine vessels in six patients with severe post-SAH vasospasm were stented. The stents were deployed in 16 vessel segments. All attempted implantations were technically successful. All patients demonstrated radiographic and clinical improvement of the vessel narrowing. No recurrent vasospasm or thromboembolic occlusion of the stented vessels was encountered. In long-term angiographic follow-up, neither in-stent stenosis nor stent occlusion was found.Conclusions: Endovascular implantation of self-expanding stents is a potential ultima ratio strategy for patients with severe refractory post-SAH cerebral vasospasm. Stents with reduced thrombogenicity (avoiding DAPT) and bioabsorbable self-expanding stents would further advance this concept.