Background and Purpose Subarachnoid hemorrhage in the setting of aneurysm rupture can cause result in cerebral vasospasm, the severity of which can have devastating long-term effects for patients. Multiple non-invasive medical treatments are used in the intensive care setting to prevent vasospasm, however in the cases of medically refractory, endovascular therapy with intraarterial calcium channel antagonist infusion and balloon angioplasty has been at the forefront of treatment in mitigating neurological deficits and improving outcomes.
Materials and Methods In this retrospective review, we have studied patients admitted for aneurysmal subarachnoid hemorrhage, over 12 years from July 2008-January 2020, updating single-center outcomes at UCSF and comparing outcomes to a prior study studying patient data collected from 2003-2008 (n=546).
Results Of patients studied, 931 patients suffered subarachnoid hemorrhage within 72 hours prior to admission, due to a non-traumatic cause. Approximately 4% of these patients presented with concurrent amphetamine or cocaine use. Of 931 patients, 871 patients experienced symptomatic cerebral vasospasm that was refractory to medical therapy. Of these patients 90% of patients received endovascular treatment. Overall, 3113 endovascular interventions were performed, of which there were 2665 intraarterial infusions, 8 angioplasties and 444 combined therapies (intra-arterial infusion and angioplasty). Due to persistence of vasospasm after the first endovascular session, 690 patients underwent repeat endovascular therapy (79%). While there were no major complications associated with vasospasm therapy, there were 29 minor complications related to vasospasm therapy which did not result in increased morbidity. A modified Rankin Scale (mRS) was used to determine patient outcome at the latest follow up. If a patient was lost to follow up, the latest discharge evaluation was used to determine the mRS. Patients were further categorized by the severity of hemorrhage with which they presented, by the Hunt-Hess (HH) scale. In this study, 91% patients who had a good HH (HH1-3) score had a good outcome (mRS 0-3), compared to 71% percent previously. Further, 62% of patients with a poor HH (4-5) had a good outcome, compared to 32% of patients previously. Of patients with a poor HH score initially, 36% had poor outcomes, as opposed to 40% previously. Overall, men and women had similar outcomes. Ongoing analyses include investigating the outcomes based on age, trends in doses of verapamil used, locations of vessels treated as well as concurrent medical treatments used in the ICU.
Conclusions In this updated retrospective review, outcomes have been shown to have improved in patients treated with endovascular therapy when compared to 2003-2008. Treating patients with a combination of angioplasty and verapamil is effective in treating patients with vasospasm. Understanding how changes in treatment modalities both in the endovascular setting and in the ICU have impacted outcomes in the recent decade, we can continue to improve the quality of life for patients with subarachnoid hemorrhage.
Disclosures M. Duvvuri: None. R. Ramesh: None. S. Hetts: None.
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