High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm.

BACKGROUND: There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE: To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS: We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS: Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS: High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.

The natural history of "contrast stasis" within aneurysm after embolization.

OBJECTIVE: Contrast stasis within residual aneurysm sac is sometimes seen after embolization of intracranial aneurysms and is thought to represent sluggish flow prone to thrombosis. We report the short- and intermediate-term angiographic outcomes of intra-aneurysmal contrast stasis following predominantly bioactive coil embolization procedures. DESIGN/METHODS: Contrast stasis was identified by retrospective review of 153 consecutive patients treated at two centers with endovascular embolizations for intracranial aneurysms. Contrast stasis was defined by persistent opacification despite clearance of contrast from parent artery assessed during angiography at 3-5 frames/second. The contrast stasis were classified based on relative area and location visualized on dynamic angiographic images as small (5-15% of the total aneurysm), large (> 15%), or occurring only in the aneurysm neck by an independent reviewer. RESULTS: There were 44 patients (23 women: mean age 54.3±12.5 years) who had contrast stasis; 36 patients had small and 8 had contrast stasis in the neck of the aneurysm. There were no patients with large contrast stasis. Of these 44 patients, 33 patients had a mean follow up angiogram in 269.5 days; 10 patients had no follow up. In 21 patients, (18 were small and 3 were in the neck) the area of contrast stasis had spontaneously thrombosed while in 7 patients there was no change in the contrast stasis. The remaining 5 patients had increase in area of contrast stasis and required re-embolization. Size of the contrast stasis (p= 0.02) was the only statistically significant factor although there was a trend dome to neck ratio > 2 (p= 0.16) and washout on the initial angiogram (p= 0.16) affecting the thrombosis of contrast stasis. CONCLUSIONS: Most small contrast stasis following coil embolization procedures spontaneously thrombose and do not require further treatment. A small proportion of patients had increase in the area of intra-aneurysmal contrast stasis and required further treatment. ABBREVIATIONS: MRAmagnetic resonance angiographyDSAdigital subtraction angiography.