THE EFFICACY AND SAFETY OF ANGIOPLASTY FOR CEREBRAL VASOSPASM AFTER SUBARACHNOID HEMORRHAGE

OBJECTIVE: Cerebral angioplasty is being increasingly used for symptom atic vasospasm secondary to subarachnoid hemorrhage. We attempted to d etermine the safety and efficacy of angioplasty for refractory vasospa sm. We also looked at the influence of timing of angioplasty on outcom e. METHODS: We retrospectively studied patients with subarachnoid hemo rrhage who underwent angioplasty in our institution to determine the s afety and the success rate achieved with this procedure. The study per iod extended from August 1993 until February 1997. Clinical and radiol ogical data were collected, with emphasis on clinical improvement afte r angioplasty and its relationship with timing of intervention. Thirty -one patients with 43 aneurysms and one case of arteriovenous malforma tions were included. Their ages varied between 28 and 68 years, with a n average age of 44 years. Five patients were assigned Hunt and Hess G rade IV, 15 were assigned Grade III, 7 were assigned Grade II, and 4 w ere assigned Grade I. All patients except two underwent angioplasty af ter aneurysm clipping or coiling. RESULTS: Angioplasty was performed a n average of 6.9 days after the occurrence of subarachnoid hemorrhage, with a range from 1 to 14 days. It was performed early (within 24 h) after refractory clinical deterioration in 21 patients. A total of 81 vessels were dilated. Three angioplasty-related complications occurred : two femoral hematomas and one retroperitoneal hematoma. Clinical imp rovement was dramatic after 12 procedures, moderate after 11 procedure s, and minimal or nonexistent after 9 procedures. There was a clear te ndency toward more significant improvement in patients with earlier an gioplasty (<24 h from onset of neurological deficit) (P = 0.0038). At discharge, 8 patients had achieved good recoveries (Glasgow Outcome Sc ale score of 1), 11 had moderate disabilities (Glasgow Outcome Scale s core of 2), and 10 had severe disabilities (Glasgow Outcome Scale scor e of 3). Two deaths were encountered, and they were unrelated to angio plasty. Follow-up was obtained for 27 patients: 25 had good outcomes, 1 was moderately disabled, and 1 died. There was no significant correl ation between interval and outcome. CONCLUSION: Our results indicate t hat angioplasty is a safe and effective treatment for symptomatic vaso spasm that is refractory to hyperdynamic hypervolemic therapy. When us ed early (<24 h), it leads to significant clinical improvement. Howeve r, the long-term outcome is good, even in cases of delayed angioplasty . The prevention of worsening of the cerebral ischemia and its extensi on to other territories may be the reason.