Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage

Abstract

Intra-arterial (IA) vasodilator therapy is one of the recommended treatments to minimize the impact of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm refractory to standard management. However, its usefulness and efficacy is not well established. We evaluated the effect IA vasodilator therapy on middle cerebral artery blood flow and on discharge outcome. We reviewed records for 115 adults admitted to Neurointensive Care Unit to test whether there was a difference in clinical outcome (discharge mRS) in those who received IA infusions. In a subset of 19 patients (33 vessels) treated using IA therapy, we tested whether therapy was effective in reversing the trends in blood flow. All measures of MCA blood flow increased from day -2 to -1 before infusion (maximum Peak Systolic Velocity (PSV) 232.2±9.4 to 262.4±12.5 cm/s [p = 0.02]; average PSV 202.1±8.5 to 229.9±10.9 [p = 0.02]; highest Mean Flow Velocity (MFV) 154.3±8.3 to 172.9±10.5 [p = 0.10]; average MFV 125.5±6.3 to 147.8±9.5 cm/s, [p = 0.02]) but not post-infusion (maximum PSV 261.2±14.6 cm/s [p = .89]; average PSV 223.4±11.4 [p = 0.56]; highest MFV 182.9±12.4 cm/s [p = 0.38]; average MFV 153.0±10.2 cm/s [p = 0.54]). After IA therapy, flow velocities were consistently reduced (day X infusion interaction p<0.01 for all measures). However, discharge mRS was higher in IA infusion group, even after adjusting for sex, age, and admission grades. Thus, while IA vasodilator therapy was effective in reversing the vasospasm-mediated deterioration in blood flow, clinical outcomes in the treated group were worse than the untreated group. There is need for a prospective randomized controlled trial to avoid potential confounding effect of selection bias.

Morphological changes of intracranial pressure quantifies vasodilatory effect of verapamil to treat cerebral vasospasm

“…In this pilot study of 21 patients with aneurysmal SAH and angiographic vasospasm, we evaluated daily TCD recordings and found that CBFV increased in the days leading up to EVT, which is in accordance with the results of Daftari Besheli et al 43. Moreover, the observation that the MCA and ACA seemed to conform to a similar response, whereas ICA did not change, would further support the proposal that verapamil affects the distal rather than the proximal arteries.…”

Comment on pediatric living donor liver transplantation decade progress in Shanghai: Characteristics and risks factors of mortality

“…Interquartile range (IQR) is the difference between the third quartile (Q3: 75%) and the first quartile (Q1: 25%) of a given variable, and therefore, IQR is supposed to be a single number. The authors have given the variable range (Q1-Q3) under IQR, which is not the IQR itself[ 4 , 5 ]. This is an important error from a statistical point of view.…”