The prophylactic use of transluminal balloon angioplasty in patients with Fisher Grade 3 subarachnoid hemorrhage: a pilot study

Object. Recent advances in neuroradiology have made it possible to dilate v asospastic human cerebral arteries after aneurysmal subarachnoid hemorrhage (SAH), but the time window is short and the success rate for reversal of d elayed ischemic neurological deficits (DINDs) varies between 31% and 77%. I n a dog model of vasospasm, transluminal balloon angioplasty (TBA) performe d on Day 0 totally prevented the development of angiographically demonstrat ed narrowing on Day 7. Because the effect of preventive TEA in this animal model was better than any pharmacological treatment described previously fo r experimental vasospasm, the authors conducted a pilot trial in humans to assess the safety and efficacy of TBA performed within 3 days of SAH. Methods. The study group consisted of 13 patients with Fisher Grade 3 SAH w ho had a very high probability of developing vasospasm. in all patients, re gardless of the site of the ruptured aneurysm, target vessels for prophylac tic TBA were as follows: the internal carotid artery, A(1) segment, M-1 seg ment, and P-1 segment bilaterally; the basilar artery; and one vertebral ar tery. Prophylactic TBA was considered satisfactory when it could be perform ed in at least two of the three parts of the intracranial circulation (righ t and/or left carotid system and/or vertebrobasilar system), and included t he aneurysm-bearing part of the circulation. Of the 13 patients, none devel oped a DIND or more than mild vasospasm according to transcranial Doppler u ltrasonography criteria. At 3 months posttreatment eight patients had made a good recovery, two were moderately disabled, and three had died; one pati ent died because of a vessel rupture during TBA and two elderly individuals died of medical complications associated with poor clinical condition on a dmission. Conclusions. Compared with large series of patients with aneurysmal SAH rep orted in the literature, the results of this pilot study indicate an extrem ely low incidence of vasospasm and DIND after treatment with prophylactic T BA. A larger randomized study is required to determine whether prophylactic TBA is efficacious enough to justify the risks, and which vessels need to be dilated prophylactically.