Innovation in the Management of Delayed Cerebral Ischemia in Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is one of the feared stroke subtypes with a high degree of morbidity and mortality. Even after the initial treatment of the ruptured aneurysm, patients remain critically ill due to numerous neurologic and systemic sequalae. Among them is cerebral vasospasm, which is a key contributor in the development of delayed cerebral ischemia (DCI). Whereas prevention of DCI with oral nimodipine is standard of care, neurointerventional strategies in the management of DCI are varied. Chemical angioplasty with intra-arterial vasodilators has been a conventional approach when noninvasive medical management fails but is associated with the need for retreatment and therefore felt to be least durable. Balloon angioplasty is also another classically employed, but less frequent intervention, and is limited by utility in the proximal arterial segment, a narrower safety profile, and challenging navigability. More recently, the use of retrievable stents is emerging as a novel strategy with the advantages of improved safety profile, and navigability to treat more distal segments. Here, a selective overview of some of these classic and innovative neurointerventional strategies is presented in the treatment of symptomatic vasospasm/DCI.