Haemodynamic and anaesthetic management of patients undergoing endovascular therapy for cerebral vasospasm

Abstract Background: Cerebral vasospasm is a common and devastating complication after a subarachnoid haemorrhage (SAH). Current guidelines for treatment recommend hypertension with euvolaemia. Endovascular therapy with cerebral angioplasty and possible administration of intra-arterial vasodilators is indicated in patients who fail medical treatment. The objective of our study was to review the haemodynamic management and anaesthetic care of patients undergoing endovascular therapy for cerebral vasospasm in our institution. Materials and Methods: The medical records of all patients who underwent endovascular therapy for cerebral vasospasm between, April 2006 and September 2012, were reviewed retrospectively. Patients with clinical vasospasm were treated initially by inducing hypertension to systolic pressures of 140 to 170 mmHg; Endovascular treatment was performed, if there was no clinical improvement. Data was collected on blood pressure measurements, anaesthetic management, duration and complications of hypertensive therapy and outcome. The differences in the pre- and post-angioplasty systolic blood pressure were statistically analysed. Results: A total of 45 patients had 47 endovascular interventions, with balloon angioplasty for proximal vessel spasm and 16 (34%) patients had additional intra-arterial injection of a vasodilator agent. Onset of vasospasm was 7 days (range 2-15 days) after SAH. Vasospasm was usually seen in multiple vessels in the same patient regardless of the site of ruptured aneurysm and was present unilaterally in 80% of the patients. All patients had a general anaesthesia for the procedure. Prior to endovascular treatment 68.9% patients required vasopressors, but post angioplasty 93.3% required them. Norepinephrine was the most commonly used (66.2%). Angioplasty was successful in reversing the cerebral vasospasm as assessed by angiography in all patients with no intra-procedure complications. Overall 80% of patients were discharged from hospital to home or to a rehabilitation centre. Conclusion: Cerebral vasospasm affects multiple vessels in the same patient. Despite endovascular therapy being a successful intervention for proximal vessel spasm, most patients still required induced hypertension with even higher levels post angioplasty compared to pre angioplasty.