Intracranial stenting as a bail-out option for posthemorrhagic cerebral vasospasm: a single-center experience with long-term follow-up

Abstract

Background Cerebral vasospasm (CVS) is a leading cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage (aSAH). Endovascular treatment, including intraarterial infusion of drugs with vasodilation effects, and balloon- and stentriever angioplasty, are helpful but may achieve only short-term effects. There is a clinical need 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 (Group 1) or as a bail-out strategy after failed intraarterial drug infusion or mechanical treatment (Group 2). All stented patients received dual antiplatelet therapy (DAPT) for 6 months. 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 permanent vessel occlusion of the stented vessels was encountered. A thrombus formation in a Group 1 patient resolved under 4 mg eptifibatide IA infusion. During 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 might further advance this concept. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02862-4.

Neuroradiological diagnosis and therapy of cerebral vasospasm after subarachnoid hemorrhage

“…Moreover, there are also descriptions of the use of stent angioplasty as an ultima ratio option for treating CVS. However, this strategy is limited to individual centers [74].…”

“…Wir selbst haben in unserer Institution mit dem Comaneci-Instrument unter Nutzung einer verstellbaren und dabei gut steuerbaren Radialkraft positive Erfahrungen bei der endovaskulären Behandlung von ZVS gesammelt. Außerdem lassen sich als Ultima Ratio-Option auch Beschreibungen dauerhafter Stentangioplastien zur Behandlung von ZVS finden, die allerdings auf einzelne Zentren beschränkt sind 74 .…”

Evaluation of DeGIR registry data on endovascular treatment of cerebral vasospasm in Germany 2018–2021: an overview of the current care situation

“…Außerdem kommen lokale medikamentöse Dauertherapien unter Verwendung von Mikrokathetern sowie Gefäßdilatationen mit Stentretrievern oder anderen nicht okklusiven Stents zur Anwendung [13][14][15]. Ferner sind bei rekurrenten ZVS auch Fallserien zur dauerhaften Stentangioplastie zu finden [16]. Generell fehlen bislang konsentierte Empfehlungen zur Indikation und standardisierten Durchführung von EST.…”

“…Interessant erscheint auch die Häufigkeit des Stentings in 176 Fällen aller EST (2,3 %). Solche Implantationen sind in der Literatur als "Bail-out"-Optionen vorbeschrieben [16].…”

“…In addition, topical long-term drug therapies using microcatheters and vascular dilatation with stent retrievers or other non-occlusive stents are used [13][14][15]. Furthermore, in the case of recurrent CVS, case series on long-term stent angioplasty can also be found [16]. In general, there is a lack of agreed recommendations on the indication and standardized implementation of EVT to date.…”