Temporal evolution of vasospasm and clinical outcome after intra-arterial vasodilator therapy in patients with aneurysmal subarachnoid hemorrhage.
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.
Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America.|Harvard Medical School, Boston, MA, United States of America.
Laleh
L
Daftari Besheli
Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America.|Harvard Medical School, Boston, MA, United States of America.|Cerebrovascular Research Laboratory, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA, United States of America.
Can Ozan
CO
Tan
Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America.|Harvard Medical School, Boston, MA, United States of America.
Donnie L
DL
Bell
Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America.|Harvard Medical School, Boston, MA, United States of America.
Joshua A
JA
Hirsch
Department of Radiology, Massachusetts General Hospital Boston, MA, United States of America.|Harvard Medical School, Boston, MA, United States of America.
Rajiv
R
Gupta
D001783:Blood Flow Velocity / Q000187:drug effects; D002560:Cerebrovascular Circulation / Q000187:drug effects; D018450:Disease Progression; D005260:Female; D006801:Humans; D007261:Infusions, Intra-Arterial; D008297:Male; D008875:Middle Aged; D020768:Middle Cerebral Artery / Q000000981:diagnostic imaging / Q000187:drug effects; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000000981:diagnostic imaging; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D020301:Vasospasm, Intracranial / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000209:etiology
D014665:Vasodilator Agents