Endovascular management of cerebral vasospasm

Cerebral vasospasm is a cause of significant morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Most cases of vasospasm can be managed medically. Medical strategies for treatment include hemodynamic augmentation to improve cerebral perfusion pressure and medical therapy to prevent or reduce cerebral vasospasm. In patients with acute neurological deterioration, imaging assessment is essential to triage those patients appropriate for aggressive medical or endovascular therapy. Such imaging assessment can be performed with many radiologic techniques such as transcranial Doppler, computed tomography (CT), magnetic resonance imaging, and single-photon emission CT (SPECT). Advanced CT applications like CT angiography and CT perfusion are gaining popularity and playing an increasingly important role in the decision making. Endovascular techniques for treatment of vasospasm include intra-arterial administration of vasodilators and intracranial angioplasty. This article discusses the use of these endovascular techniques in the management of vasospasm and provides a current review of literature. Sustained efficacy of intra-arterial vasodilators is less well established at this time, and repeated treatments may be necessary. Balloon angioplasty is an effective technique in treating vasospasm and results in durable clinical improvement. It should be used judiciously, however, given a small risk of vessel rupture associated with intracranial angioplasty. The goal of angioplasty should be improvement of vessel caliber to augment flow rather than to achieve a picture-perfect result.