title: Institution of sustained endovascular treatment prior to clinical deterioration in patients with severe angiographic vasospasm: A retrospective observational study of clinico-radiological outcomes.
abstract: Severe angiographic vasospasm (aVSP) is a risk factor for infarction following subarachnoid haemorrhage and infarction is strongly associated with poor outcome. We present the clinico-radiological results of cohort with severe aVSP who underwent a program of angiographic surveillance and sustained endovascular treatment using multiple verapamil infusions and/or transluminal balloon angioplasty (TBA).
  
  
  METHODS
  This was a dual-centre retrospective observational study. Angiographic screening for vasospasm was undertaken at days 5-7 post-ictus. Treatment was instituted principally on the basis of radiographic findings. The rate of infarction was evaluated on follow-up CT. Clinical outcome was assessed using the modified Rankin Scale (mRS).
  
  
  RESULTS
  Fifty-seven WFNS grades 1-5 patients were studied. The mean number of procedures/patient was 6, range 2-13. Mean verapamil dose administered to the ICA was 14 mg and VA was 12 mg. Thirty-one patients underwent TBA (52.6%). The rate of proximal vessel infarction was 3/45 (6.7%) for patients presenting <72 hours. Rates of favourable outcome (mRS 0-2) were 16/19 (84.2%) for WFNS grades 1-2, 12/19 (63.2%) for grades 3-4 and 5/19 (26.3%) for grade 5 patients. Delayed presentation >72 hours was the only factor on multivariate analysis to significantly predict aVSP-infarction [OR19.3 (3.2-116.6) P=0.0012]. Large aVSP-infarction [OR19.0 (1.7-216.4) 0.0179] and poor WFNS grade [OR 6.6 (1.3-33.9) P = 0.0233] were significant predictors of poor outcome on multivariate analysis.
  
  
  CONCLUSIONS
  This approach may result in low rates of aVSP-infarction and encouraging rates of favourable outcome when compared to literature benchmarks. Delayed presentation, however, predicts infarction and large infarct and poor initial grade significantly influence functional outcome.
authors: Department of Radiology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065 Sydney, Australia. Electronic address: alex_mortimer@hotmail.com.
authors: Alex Mark
authors: AM
authors: Mortimer
authors: Department of Radiology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065 Sydney, Australia; Department of Neurosurgery, Westmead Hospital, Sydney, Australia.
authors: Brendan
authors: B
authors: Steinfort
authors: Department of Radiology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065 Sydney, Australia; Department of Neurosurgery, Westmead Hospital, Sydney, Australia.
authors: Ken
authors: K
authors: Faulder
authors: Department of Radiology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065 Sydney, Australia.
authors: Tian
authors: T
authors: Erho
authors: Department of Neurosurgery, Westmead Hospital, Sydney, Australia.
authors: Mark
authors: M
authors: Dexter
authors: Department of Neurosurgery, Royal North Shore Hospital, Sydney, Australia.
authors: Nazih
authors: N
authors: Assaad
authors: Department of Radiology, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065 Sydney, Australia.
authors: Timothy
authors: T
authors: Harrington
mesh_terms: D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*
keywords: Angioplasty; DIND; Delayed ischaemia; Endovascular; Infarction; Stroke; Subarachnoid hemorrhage; Vasospasm; Verapamil