Vasospasm in Aneurysmal

Subarachnoid Hemorrhage:
Diagnosis, Prevention,
and Management
Vallabh Janardhan,
Neuroimag Clin N Am 16 (2006) 483496
Neuroimag Clin N Am 16 (2006) 483496

Neuroimagin Clin North America 16(2006) 483-496

Indication and timing for endovascular therapy

The indications for endovascular therapies, namely intra-arterial
infusion of vasodilators and or percutaneous transluminal balloon
angioplasty (PTA), include:
- Symptomatic vasospasm refractory to medical therapy
- Neurological deficits referable to the vascular territory of the
angiographic vasospasm
- Vessel diameter reduction between 25% and 50% of the initial
angiographic diameter for intraarterial infusion of vasodilators
- Vessel diameter reduction greater than 50% of the initial
diameter angiographically for PTA
- No evidence of any hypodensity on noncontrast head CT scan
suggestive of ischemic infarct caused by vasospasm before the
angiogram
Early endovascular therapy within 2 hours of VSP becoming
refractory to medical therapy has been shown to be associated with
improved outcomes
Angioplasty protocol for vasospasm at the authors Institution
All patients undergo transfemoral biplane cerebral angiography
under general anesthesia with placement of a 6-French sheath.
Unfractionated heparin bolus to achieve an activated clotting time of
twice baseline is administered to all patients. All patients have arterial
lines and intracranial pressure monitors. The authors use the 4 mm x 10
mm MTI Hyperglide balloon catheter for proximal vessel PTA. They use
the 4 mm x 7 mm Micro Therapeutic, Incorporated ([MTI] Irvine,
California) Hyper- Form occlusion balloon catheter and X-pedion-10
support hydrophilic guidewire for distal PTA. The techniques employed at
the authors institution are as follows:
- The balloon is inflated with a dilution of 75% Omnipaque (iohexol,
300 milligrams of Iodine/mL, Amersham Health Incorporated, Princeton,
New Jersey) and 25% normal saline allowing a good balloon visibility.

- The use of MTI Cadence Precision Injector Threaded 1 mL syringe

(Micro Therapeutic, Incorporated, Irvine, California) offers a more precise
control of the inflation volume (each turn of the threaded precision
injector is equivalent to 0.02 mL, and for distal
PTA 0.04 mL is the maximum injected).
- To test the balloon visibility, a test inflation of the balloon is
performed in the proximal ICA or vertebral artery before PTA.
- In patients with severe vasospasm, intraarterial infusion of
vasodilators (verapamil) in small doses is used to dilate the vessels to
facilitate advancing the balloon catheter before PTA.
- Baseline (before vasospasm) angiogram is necessary to
determine the prespasm size of the vessels. A final biplane angiography
is performed and compared with before angioplasty and baseline
angiograms.
Hemostasis is obtained by using a femoral arterial closure device.