Clinical Neurology and Neurosurgery 118 (2014) 26–31 Contents lists available at ScienceDirect Clinical Neurology and Neurosurgery journal h om epa ge : www.elsevier.com/locate/clineuro Endovascular management of cerebral vasospasm following aneurysm rupture: Outcomes and predictors in 116 patients Nohra Chalouhi a , Stavropoula Tjoumakaris a , Vismay Thakkar a , Thana Theofanis a , Christine Hammer a , David Hasan b , Robert M. Starke a , Chengyuan Wu a , L. Fernando Gonzalez a , Robert Rosenwasser a , Pascal Jabbour a,∗ a Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, USA b Department of Neurosurgery, University of Iowa, Iowa City, USA a r t i c l e i n f o Article history: Received 12 October 2013 Received in revised form 11 November 2013 Accepted 25 December 2013 Available online 4 January 2014 Keywords: Aneurysm Balloon angioplasty Vasospasm Nicardipine a b s t r a c t Objective: To retrospectively assess the safety and efficacy of endovascular treatment of cerebral vasospasm with different modalities and assess predictors of outcome. Methods: Endovascular treatment was indicated in the event of neurological deterioration refractory to medical therapy. Data were collected for 116 patients treated at our institution. Results: Vasospasm was treated with balloon angioplasty in 52.6%, intra-arterial nicardipine infusion in 19.8%, or both in 27.6%. Angiographic vasospasm was reversed in all but 4 (96.6%) patients. The com- plication rate was 0.9%. Twenty patients (17.2%) had incipient pre-procedure hypodensities; 3 (15%) hypodensities were reversed and neurological improvement occurred in 60% of these patients. Retreat- ment was required in 22 (19%) patients. Higher Hunt and Hess grades and treatment with nicardipine alone predicted retreatment. Neurological improvement was noted in 82%. Male gender, pre-procedure hypodensities, and posterior communicating artery aneurysm location negatively predicted neurolog- ical recovery. Favorable outcomes were noted in 73%. Higher Hunt and Hess grades, pre-procedure hypodensities, posterior circulation aneurysms, and no neurological recovery predicted poor outcome. Conclusion: Endovascular therapy for vasospasm has an excellent safety-efficacy profile. Balloon angio- plasty and nicardipine are equally effective but effects of nicardipine are less durable. Patients with incipient pre-procedure hypodensities benefit from endovascular intervention and should probably not be excluded from treatment. © 2014 Elsevier B.V. All rights reserved. 1. Introduction Cerebral vasospasm is a major cause of morbidity and mortal- ity in patients who survive aneurysmal subarachnoid hemorrhage (SAH) [1]. Angiographic vasospasm occurs in 30–70% of patients following aneurysm rupture, most commonly between days 3 and 12, and results in permanent morbidity or mortality in up to 20% of these patients [2]. Symptomatic vasospasm refractory to hemodynamic augmen- tation is an indication for endovascular treatment with balloon angioplasty (BA) and/or vasodilators (nicardipine in our center) [3,4]. Most studies on endovascular treatment of vasospasm were conducted more than a decade ago and have focused mainly ∗ Corresponding author at: Division of Neurovascular Surgery and Endovascular Neurosurgery, Department of Neurological Surgery, Thomas Jefferson University Hospital, 901 Walnut Street, 3rd Floor, Philadelphia, 19107, USA. Tel.: +1 2159557000; fax: +1 2155037038. E-mail addresses: pascal.jabbour@jefferson.edu, dpj52@hotmail.com (P. Jabbour). on balloon angioplasty and papaverine, with limited data avail- able on newer agents such as nicardipine [5–9]. It also remains unknown which treatment modality (intra-arterial vasodilators vs. balloon angioplasty vs. combination of both) offers patients the best chance for a favorable outcome. Furthermore, very few stud- ies have assessed the overall predictors of outcome in patients undergoing endovascular treatment for vasospasm. Patients with poor prognostic factors could benefit from earlier, more aggressive endovascular intervention. In this study, we assess the safety and efficacy of endovascu- lar treatment of cerebral vasospasm with different modalities and assess the predictors of neurological improvement, post-procedure infarcts, retreatment, and clinical outcome in a large series of 116 patients treated at our institution. 2. Methods The university institutional review board approved the study protocol. Consecutive patients who underwent endovascular ther- apy for treatment of vasospasm after aneurysmal SAH between 0303-8467/$ – see front matter © 2014 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.clineuro.2013.12.012