title: Endovascular Rescue Therapies for Refractory Vasospasm After Subarachnoid Hemorrhage: A Prospective Evaluation Study Using Multimodal, Continuous Event Neuromonitoring.
abstract: BACKGROUND
  Critical hypoperfusion and metabolic derangement are frequently encountered with refractory vasospasm. Endovascular rescue therapies (ERT) have proven beneficial in selected cases. However, angioplasty (AP) and intraarterial lysis (IAL) are measures of last resort and prospective, quantitative results regarding the efficacy (cerebral oxygenation, metabolism) are largely lacking.
  
  
  OBJECTIVE
  To evaluate the efficacy of ERTs for medically refractory vasospasm using multimodal, continuous event neuromonitoring.
  
  
  METHODS
  To detect cerebral compromise in a timely fashion, sedated patients with aneurysmal subarachnoid hemorrhage received continuous neuromonitoring (p ti O 2 measurement, intraparenchymal microdialysis). ERT (AP and/or IAL) was considered in cases of clinically relevant vasospasm refractory to conservative treatment measures. Oxygen saturation and cerebral and systemic metabolism before and after events of ERT was recorded.
  
  
  RESULTS
  We prospectively included 13 consecutive patients and recorded a total of 25 ERT events: AP (n = 10), IAL (n = 11), or both (AP + IAL, n = 4). Average cerebral p ti O 2 was 10 ± 11 torr before and 49 ± 22 torr after ERT ( P < .001), with a lactate-pyruvate ratio decreasing from 146.6 ± 119.0 to 27.9 ± 10.7 after ERT ( P < .001). Comparable improvement was observed for each type of intervention (AP, IAL, or both). No significant alterations in systemic metabolism could be detected after ERT.
  
  
  CONCLUSIONS
  Multimodal event neuromonitoring is able to quantify treatment efficacy in subarachnoid hemorrhage-related vasospasm. In our small cohort of highly selected cases, ERT was associated with improvement in cerebral oxygenation and metabolism with reasonable outcome. Event neuromonitoring may facilitate individual and timely optimization of treatment modality according to the individual clinical course.
authors.affiliation: Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
authors.forename: Walid
authors.initials: W
authors.lastname: Albanna
authors.affiliation: Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
authors.forename: Miriam
authors.initials: M
authors.lastname: Weiss
authors.affiliation: Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany.
authors.forename: Marguerite
authors.initials: M
authors.lastname: Müller
authors.affiliation: Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany.
authors.forename: Marc Alexander
authors.initials: MA
authors.lastname: Brockmann
authors.affiliation: Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Aachen, Germany.
authors.forename: Annette
authors.initials: A
authors.lastname: Rieg
authors.affiliation: Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
authors.forename: Catharina
authors.initials: C
authors.lastname: Conzen
authors.affiliation: Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
authors.forename: Hans
authors.initials: H
authors.lastname: Clusmann
authors.affiliation: Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
authors.forename: Anke
authors.initials: A
authors.lastname: Höllig
authors.affiliation: Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
authors.forename: Gerrit Alexander
authors.initials: GA
authors.lastname: Schubert
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D064926:Neurophysiological Monitoring / Q000379:methods; D011446:Prospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000209:etiology* / Q000601:surgery*
keywords: Angioplasty; Brain tissue oxygen; Endovascular; Neuromonitoring; Subarachnoid hemorrhage; Vasospasm