The Source for Neurovascular News and Education

March 28, 2024

 

Older age and smoking status remain key players, but there’s much more left to learn, experts told NVX.

 

Older age and smoking remain important predictors of poor outcome among patients with aneurysmal subarachnoid hemorrhage treated endovascularly for vasospasm, according to a recent retrospective analysis. In addition, initial use of angioplasty may be associated with a reduced need to retreat. The findings were published online recently ahead of print in the Journal of NeuroInterventional Surgery.

 

In a joint comment about the study for Neurovascular Exchange, Edward Vates, MD, and James E. Towner, MD (University of Rochester Medical Center, Rochester, NY), explained that while subarachnoid hemorrhage accounts for only about 5% of all strokes, these events are clinically important.

 

“They disproportionately affect younger patients, so any interventions which alter outcome will have long-lasting effects on the societal impact of this disease,” the experts said. “One of the most significant contributors to poor outcomes in [aneurysmal subarachnoid hemorrhage] is vasospasm, and the efficacy of treatment modalities has not been rigorously investigated.”

 

Vasospasm tends to occur in about two-thirds of patients with subarachnoid hemorrhage, they continued, usually between days 3 and 21 posthemorrhage. About one-third of those affected experience symptoms. Delayed cerebral ischemia (DCI) is the clinically significant end result and the key outcome that clinical interventions attempt to prevent.

 

The study authors, led by Jennifer D Sokolowski, MD (University of Virginia Health System, Charlottesville, VA), retrospectively assessed the baseline and outcomes data for 159 patients with aneurysmal subarachnoid hemorrhage who underwent endovascular vasospasm treatment at their institution, including intra-arterial vasodilator infusion and angioplasty.

 

Patients’ mean age was 52. A good outcome, defined as an mRS 0-2, was achieved in 26 of 150 patients (17%) at discharge. The in-hospital mortality rate was 22% (33/150).

 

Multivariate analysis revealed that both age and positive smoking status were negative independent predictors of good outcome.

 

Negative Predictors of Good Outcome

 

Adjusted OR

(95% CI)

P Value

Older Age

0.895

(0.823-0.973)

0.009

Positive Smoking Status

0.206

(0.046-0.932)

0.04

 

Endovascular retreatment was performed in 53 of 156 patients (34%). Among these patients, the initial vasospasm therapies more frequently employed verapamil as the vasodilatory agent (96.2% vs 76.7%, P = 0.006) and less frequently employed angioplasty (20.8% vs 39.8%, P = 0.017).

 

Among patients who underwent endovascular retreatment, negative independent predictors of good outcome were older age, symptomatic vasospasm, initial treatment with angioplasty alone, and initial treatment with combined intra-arterial vasodilator infusion and angioplasty.

 

Negative Predictors of Good Outcome After Endovascular Retreatment

 

Adjusted OR

(95% CI)

P Value

Older Age

0.950

(0.918-0.984)

0.004

Symptomatic Vasospasm

0.441

(0.197-0.987)

0.046

Initial Retreatment With Angioplasty Alone

0.096

(0.010-0.889)

0.039

Initial Retreatment With Intra-Arterial Vasodilator + Angioplasty

0.342

(0.132-0.879)

0.026

 

According to Vates and Towner, these findings are largely in line with previous studies of subarachnoid hemorrhage. But there were some novel outcomes as well.

 

“Older age was associated with undergoing fewer invasive treatments for vasospasm, which possibly suggests a diminished propensity to re-spasm and may be useful in counseling patients and their families,” they pointed out. “Alternatively, older patients may simply receive fewer treatments. There was also a negative association between balloon angioplasty and requiring endovascular retreatment, supporting the commonly-held belief that angioplasty is more durable than intra-arterial infusion of antispasmolytics in the treatment of vasospasm.”

 

The findings also underscore the complexity of DCI, the commentators told NVX, given the high rates of poor outcome and in-hospital mortality.

 

Questions Remain

 

Yet the study does have its limitations, they said. “When discussing vasospasm, it is important to differentiate radiographic vasospasm from symptomatic vasospasm and DCI,” noted Vates and Towner. “This study included patients treated for radiographic vasospasm identified on a routine follow-up angiogram 1 week after aneurysm rupture, as well as those developing neurologic deficits refractory to induced hypertension. Because these groups may reflect two different clinical entities, the study’s results may not offer insight into clinical management of these somewhat distinct cohorts.”

 

In addition, patients in this study were only treated with two antispasmolytics: verapamil and papaverine. “Thus, the efficacy of alterative agents and the outcomes associated with their use are not addressed,” they explained.

 

Finally, the balloon angioplasty group may contain selection bias, since this approach is only feasible in large vessel vasospasm, and patients with more diffuse and/or significant vasospasm would more likely receive intra-arterial anti-spasmolytic therapy.

 

“Higher quality evidence of the effect of endovascular therapy on management of vasospasm and long-term outcomes in the form of randomized controlled trials is necessary to guide therapy,” Vates and Towner added. In addition, the use of induced hypertension remains an open question not addressed in this study.

 


Source:

Sokolowski JD, Chen CJ, Ding D, et al. Endovascular treatment for cerebral vasospasm following aneurysmal subarachnoid hemorrhage: predictors of outcome and retreatment. J NeuroInterv Surg. 2017;Epub ahead of print.

 

Disclosures:

Sokolowski, Vates, and Towner report no relevant conflicts of interest.