Elsevier

World Neurosurgery

Volume 98, February 2017, Pages 189-197
World Neurosurgery

Original Article
Safety and Efficacy of Noncompliant Balloon Angioplasty for the Treatment of Subarachnoid Hemorrhage–Induced Vasospasm: A Multicenter Study

https://doi.org/10.1016/j.wneu.2016.10.064Get rights and content

Objective

Cerebral vasospasm following subarachnoid hemorrhage is the most important cause of neurologic decline after successful treatment of the ruptured aneurysm. We report safety and efficacy of noncompliant balloon angioplasty for treatment of cerebral vasospasm.

Methods

Three major U.S. academic institutions provided data on cerebral vasospasm treated with noncompliant balloon angioplasty between October 2004 and February 2016. Baseline characteristics, procedure details, and radiographic and clinical outcome data were collected and analyzed.

Results

There were 52 patients (median age 50 years; range, 27–73 years) who underwent 165 noncompliant balloon angioplasty procedures. Balloon angioplasty was performed most frequently in the middle cerebral artery (MCA) (49.1%) followed by the internal carotid artery (27.2%). Improvement in vasospasm severity occurred in 160 arteries (97.0%) without procedure-related complications. No independent predictor of angioplasty success was identified on multivariate analysis. Delayed cerebral ischemia occurred in 24 patients (46.2%) encompassing 36 vascular territories. The rate of delayed cerebral ischemia in territories supplied by vessels that underwent angioplasty at least once was 29.4%, 24.2%, 19.3%, and 0% for the anterior cerebral artery (ACA) territory, internal carotid artery territory (ACA, ACA/MCA watershed, or MCA), MCA territory, and posterior circulation.

Conclusions

Our data suggest that noncompliant balloon angioplasty for treatment of subarachnoid hemorrhage–induced cerebral vasospasm is safe and effective. No predictors of angioplasty success were identified. The rate of delayed cerebral ischemia in territories supplied by vessels that underwent angioplasty was highest in the ACA territory and lowest in the posterior circulation.

Introduction

Balloon angioplasty is an established technique for treatment of symptomatic large artery vasospasm after subarachnoid hemorrhage (SAH) that is refractory to hyperdynamic therapy.1, 2 Angioplasty involves the use of 1 of 2 types of balloons: compliant or noncompliant. The term “compliant” refers to the property by which a balloon's diameter (and volume) increases in response to an increase in inflation pressure.3 Although the radial force exerted by a noncompliant balloon on the parent artery's endothelial wall is greater than that of a compliant balloon, insufflation of the balloon is typically associated with a less dramatic increase in diameter.4 Similarly, the maximum inflation volume for these devices is finite, which allows for greater operator control of the balloon diameter during inflation.4 However, noncompliant balloons are more rigid compared with compliant balloons,5 raising the theoretical possibility that noncompliant balloon catheters may require sturdier microwire access for successful navigation and carry a greater level of difficulty in navigation and a higher risk of wire perforation compared with compliant balloons. Whether noncompliant balloons compare favorably with compliant balloons in the treatment of cerebral vasospasm is largely unknown. In this article, we report the efficacy and safety of noncompliant balloon angioplasty for treatment of cerebral vasospasm at 3 major academic institutions in the United States.

Section snippets

Materials and Methods

After institutional review board approval was obtained, 3 major academic institutions in the United States provided data on cerebral vasospasm treated with noncompliant balloon angioplasty between October 2004 and February 2016. Baseline characteristics (sex, age, and smoking history), SAH grade (Hunt and Hess grade and modified Fisher score), aneurysm characteristics (size and location), aneurysm treatment (microsurgical clipping vs. endovascular embolization), balloon angioplasty procedure

Baseline Characteristics

Noncompliant balloon angioplasty for SAH-induced cerebral vasospasm was performed in 52 patients (median age 50 years; range, 27–73 years; 71.2% female) during the period 2004–2016 at 3 participating institutions (Figure 1). A history of smoking was reported by 35 (67.3%) patients. Aneurysmal SAH was present in 50 patients, whereas the SAH was from an unknown source in 2 patients. Of patients, 37 (71.2%) presented with a Hunt and Hess grade of 3–5, and 47 (90.4%) had a modified Fisher score of

Discussion

In the present study, we assessed the safety and efficacy of balloon angioplasty for SAH-induced vasospasm using noncompliant balloons at 3 major academic centers in the United States. To our knowledge, this is the largest study to date. There was improvement in angiographic vasospasm in 97% of cases without any associated procedural morbidity or mortality.

Conclusions

This multicenter, retrospective analysis found that noncompliant balloon angioplasty is safe and effective in improving radiographic vasospasm. The fixed diameter of the noncompliant balloon may limit the incidence of dissections and other intraoperative complications. No predictors of angioplasty success were identified on multivariate analysis. The rate of DCI in territories supplied by vessels that underwent angioplasty was highest in the ACA territory and lowest in the posterior circulation.

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    Several pharmacological and interventional angiographic approaches to treat vasospasm have previously been undertaken [5,6,13–15]. Patel et al. [7] observed that noncompliant balloon angioplasty reversed angiographic vasospasm in 97 % of patients, making it an effective and safe method to treat vasospasm. Previous studies have shown that interventional procedures can be used to restore regional cerebral blood flow (rCBF) reduced by vasospasm [5,13–15].

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    Noncompliant balloons may be a strategy to prevent overdilation; Patel et al19 reported an improvement of 80% and 79% in angiographic vasospasm and neurologic function, respectively, when using a noncompliant balloon. Unfortunately, noncompliant balloons can be associated with a higher recurrence rate of vasospasm and 18% of the patient's in Patel et al19 required a second treatment. Furthermore, even if vasodilation is achieved with balloon angioplasty in proximal vessels, its effects can be limited due to vasospasm in downstream cerebral vessels.

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    In our study compliant balloons were predominantly used, which did not permit a meaningful comparison due to the asymmetric distribution (89 compliant vs. 3 non-compliant balloons). A number of studies have described TBA as effective for the treatment of CVS after SAH [6,13,16,18,21–23]. Also among our patients TBA was effective with a good angiographic response in 87% of the treated vessel segments and a negative association of good angiographic response with the recurrence of CVS and subsequent vasospasm-related infarction in the multivariate analysis.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Apar S. Patel and Christoph J. Griessenauer are co–first authors.

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