Management of vasospasm in ruptured unsecured intracranial vascular lesions: review of 10 cases

Introduction: Risks associated with endovascular management remain unaddressed for post-hemorrhagic cerebral vasospasm (PHCV) caused by pathologies that cannot be secured or identified before vasospasm treatment. This retrospective study reviews our 10 year experience in the difficult scenario of subarachnoid hemorrhage (SAH) with vasospasm, including intra-arterial vasodilators or percutaneous transluminal angioplasty (PTA) to vessels feeding a ruptured unsecured lesion.

Methods: 10 SAH patients with ruptured unsecured vascular lesions underwent 44 endovascular treatments for PHCV (2002-2011). We defined unsecured as an untreated aneurysm/dissection, incompletely coiled aneurysm, dissection covered with self-expanding nitinol stents, or angiographically negative SAH. Treatments were categorized by location of the ruptured unsecured (partial or complete) lesion relative to the vessel treated for vasospasm.

Results: Our 10 patients with four aneurysms, four dissections, and two angiographically negative SAH accounted for 10.3% of SAH patients who underwent angiography for vasospasm. No procedure related complications occurred when treating vessels not supplying the index lesion or with angiographically negative SAH. Of the endovascular treated vessels supplying partially secured lesions, one (6.3%) fatal complication occurred; none of these patients receiving only vasodilators had complications. With endovascular treatment of PHCV with completely unsecured lesions, one (33%) complication was fatal.

Conclusions: Endovascular treatment appeared safe for PHCV for vessels not supplying the index arterial lesion and for angiographically negative SAH. Vasodilators were safe for vessels harboring partially secured, ruptured lesions (eg, incompletely coiled aneurysms, stented dissections). Following two major complications, the safety of administering vasodilators or performing PTA to vessels supplying completely unsecured vascular lesions remains inconclusive and should be used cautiously.