The Source for Neurovascular News and Education

June 06, 2020

 

Authors of the German study are enthusiastic about teaching the novel approach to others.

 

 

With the advent of endovascular treatment for intracranial aneurysm, removal of blood buildup in the subarachnoid space has become a new challenge, leading to the risk of delayed cerebral infarction (DCI), a complication with high morbidity and mortality rates. A team of German researchers may have solved this problem through an approach known as stereotactic catheter ventriculocisternostomy (STX-VCS).

While the number of patients treated in this manner to date is small, early results are quite promising, the investigators say.

In a joint telephone interview with Neurovascular Exchange, lead author Roland Rölz, MD, and senior author Peter C. Reinacher, MD (University of Freiburg, Germany), explained that observing the very poor outcomes in their hospital’s ICU among patients who developed DCI following aneurysmal subarachnoid hemorrhage had inspired them, in collaboration with experts in both stereotactic and general neurosurgery at their center, to develop a novel preventive therapy. The highly experimental approach was conducted in the first patient in September 2015. This report, published online September 13, 2017 ahead of print in Stroke, presents the outcomes with 20 patients.

The basic principle behind the minimally invasive procedure is simple, explained the authors. But they warned that inserting a stereotactic catheter into the subarachnoid space, with the tip coming to lie between the brain stem and dorsum sellae, is tricky. It requires placing the catheter closer than usual to critical blood vessels and eloquent brain tissue. Thus, it requires careful planning and a surgeon highly experienced in stereotactic procedures.

They say they have not had any major surgical complications to date, however.

Based on individual treatment decisions, the authors performed stereotactic catheter ventriculocisternostomy on 20 patients with aneurysmal subarachnoid hemorrhage deemed to be at high risk for DCI who were admitted to their department between September 2015 and October 2016. For each case, they compared outcomes with those of three controls who were matched for age, sex, aneurysm treatment method, and admission Hunt and Hess grade.

Continuous cisternal lavage was feasible in 17 of 20 patients (85%). Overall, DCI occurred in far more of the controls than patients who underwent STX-VCS. Use of the therapy was also associated with lower rates of mortality and a greater likelihood of being discharged to rehabilitation with a favorable outcome, defined as having an mRS ≤ 3.

 

Outcomes of STX-VCS

 

Cases

(n= 20)

Controls

(n = 60)

OR (95% CI)

DCI

15%

42%

0.15 (0.04-0.64)

Mortality

5%

33%

0.08 (0.01-0.66)

Discharge mRS ≤ 3

60%

35%

0.26 (0.8-0.86)

 

Comparatively Excellent Outcomes

The results seen here are far better than those currently achieved with conventional treatment of DCI. Most available treatments for DCI are symptomatic. STX-VCS is causal,” explained Rölz. “The only treatment for DCI reaching class I evidence is oral nimodipine, a calcium-antagonist. However, the number needed to treat is 19. Therefore, the efficacy of this treatment is very low and not without side effects. Everything beyond oral nimodipine is experimental therapy.”

Another option, hemodynamic augmentation, “is also frequently performed and partly recommended by international guidelines,” he said. “However, there is no evidence that this is helpful. Side effects are plenty. We know that the amount of increase in cerebral blood flow attained by hemodynamic manipulations is quite low.”

Rölz noted that endovascular interventions aimed at treating DCI also lack evidence to support their efficacy and all have inherent limitations.  

“Instead of waiting for vasospasm to occur, STX-VCS is meant to prevent it before it happens by eliminating its trigger,” he went on. “STX-VCS allows for removal of subarachnoid blood. If vasospasm still occurs, STX-VCS provides a continuous treatment access for the application of vasodilators (eg, nimodipine).”

To date, the most significant complication the authors have faced is irritation of the brain stem caused by insertion of the lavage solution. One patient experienced cardiac instability from this, but it was short and self-limiting. Since these patients are being treated in the ICU, they added, they are well equipped to deal with such sequelae.

The authors strongly emphasize their willingness to teach others how to perform this procedure safely and effectively. They are also in the process of planning a randomized controlled trial at their center to further evaluate its efficacy.

 


Source:

Rölz R, Coenen VA, Scheiwe C, et al. Stereotactic catheter ventriculocisternostomy for clearance of subarachnoid hemorrhage: a matched cohort study. Stroke. 2017;Epub ahead of print.

 

Disclosures:

Rölz and Reinacher report receiving a research grant from the Else Kröner-Fresenius-Stiftung.