Key result
Arterial diameter decrease of >=14% on early postoperative CTA strongly predicts vasospasm risk.
Why the study?
Cerebral vasospasm after aneurysmal subarachnoid hemorrhage remains a considerable challenge and recent treatments focusing solely on vasospasm may be outdated.
Cohort (n=100)
No
Effect estimate: AUC 0.967 (95% CI 0.931-1)
p-value: p=<0.001
May enable early CTA-based risk stratification for post-SAH vasospasm; extends imaging predictors beyond clinical monitoring in neurocritical care.
PURPOSE OF REVIEW: Cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage remains a considerable challenge in neurocritical care medicine. This review aims to cover the recent novel aspects and results in CVS treatment. RECENT FINDINGS: On the basis of the recent literature, treatment focusing on CVS alone is outdated. A considerable amount of evidence suggests CVS not to be the sole cause of delayed cerebral ischemia (DCI) and poor outcome. Early brain injury, cortical spreading depolarization, inflammation and microthrombosis have recently been discussed as additional factors. The results of a well designed phase III trial, using an endothelin-1 antagonist, indicated a decrease in the occurrence of CVS but did not change the clinical outcome significantly. Induced hypertension is currently recommended for treating suspected DCI, whereas hemodilution and hypervolemia are not. Endovascular intervention is only recommended in case of refractory symptomatic CVS. A couple of newer treatment strategies are under evaluation. Phase III trials are underway for magnesium sulfate and statins. Clinical trials aiming specifically at recently discussed factors other than CVS have not been reported. SUMMARY: Reviewing the recent literature, there have been some updates on recommendations and newer treatment modalities are under evaluation. However, a novel treatment with convincing evidence has not been reported so far.
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Muroi et al. (2012) conducted a cohort in Aneurysmal subarachnoid hemorrhage (aSAH) (n=100). Decrease in total arterial diameter on the operated side measured by early postoperative CTA vs. Lesser or no decrease in arterial diameter was evaluated on Presence of vasospasm determined by ROC analysis of the rate of decrease in total artery diameter on the operated side (AUC 0.967, 95% CI 0.931-1, p=<0.001). A decrease of 13.7% or more in total arterial diameter on the operated side on early postoperative CTA predicted the development of vasospasm with 100% sensitivity, 91.5% specificity, and an AUC of 0.967.
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