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. A previously published report detailed our experiences using these endovascular treatments in a cohort of 546 patients treated between 2003 and 2008. While both PTA and IA infusion were found to be safe in this patient pool, advancements in ICU care and interventional device technology over the past decade warrant a deeper exploration of patient selection, treatment efficacy, changes in treatments and resulting 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. Of 931 patients, 734 patients experienced symptomatic cerebral vasospasm that was refractory to medical therapy and required interventional therapy. Overall, 1720 endovascular interventions were performed, of which there were 1459 intraarterial infusions, 5 angioplasties and 256 combined therapies (intra-arterial infusion and angioplasty). There were three major complications associated with vasospasm treatment, which resulted in morbidity, and 12 minor complications. A modified Rankin Scale (mRS) was used to determine patient outcome at the latest follow up. Patients were further categorized by the severity of hemorrhage with which they presented, by the Hunt-Hess (HH) scale. In this study, 76% patients who had a good HH (HH1–3) score had a good outcome (mRS 0–3), compared to 71% percent previously. Of patients with a poor HH score initially, 58% had poor outcomes, as opposed to 40% previously. Compared to the previous retrospective study, the median dose of verapamil given during a given treatment session has increased from10 mg to 20 mg. As the severity of vasospasm increased, there was a significant increase in median dose of verapamil delivered to vessel segments. Overall, men and women had similar outcomes. Although women presented with worse Hunt-Hess grades overall, gender did not predict worsening vasospasm severity, vasospasm treatment complications or outcomes. Worse Hunt-Hess grades, and greater initial vasospasm severity was associated with worse outcomes. Increasing age was associated with worse outcomes.

Conclusions In this updated retrospective review, outcomes have not significantly improved in the past two decades, although patients appear to be receiving increased doses of verapamil per treatment session. The vasospasm treatment complication rate has not significantly increased. However, understanding why outcomes have not improved despite the introduction of intraarterial verapamil with investigations of specific endovascular treatment techniques and ICU management is critical to further improving the quality of life in patients with subarachnoid hemorrhage.

Disclosures M. Duvvuri: None. R. Ramesh: None. S. Hetts: None.