Frequency of cerebral vasospasm in patients treated with endovascular occlusion of intracranial aneurysms.

UNLABELLED: The purpose of this study was to retrospectively compare a group of 19 patients treated with craniotomy and aneurysmal clipping with a group of 18 patients who were treated via endovascular occlusion with Guglielmi detachable coils in regard to frequency and severity of cerebral vasospasm.

METHODS: All patients were treated within 48 hours of ictus. In the endovascular group, nine patients had Hunt and Hess grade I subarachnoid hemorrhage, five patients had grade II aneurysms, and four patients had grade III. According to the Fisher classification, one aneurysm was grade I, nine were grade II, and eight were grade III. Twelve of the aneurysms were on the anterior circulation and seven were on the posterior circulation. In the surgical group, 10 patients had Hunt and Hess grade I hemorrhage, seven had grade II aneurysms, and two had grade III. Nine of these were Fisher grade II and 10 were grade III. Eighteen aneurysms were on the anterior circulation and one was on the posterior circulation. Endovascularly treated patients were medically treated identically to those in the surgical group, with prophylactic volume expansion and hemodilution immediately after endovascular occlusion, except that they also received 48 hours of full heparinization followed by 24 hours of dextran infusion after endovascular occlusion.

RESULTS: All four patients in the endovascular group in whom delayed neurologic deficits developed as a result of vasospasm responded to elevation of blood pressure and did not require either mechanical or chemical angioplasty to reverse their symptomatology. In the surgical group, 14 of 19 developed clinical vasospasm, with elevation of their transcranial Doppler velocities, and required maximum triple-H (hypertensive, hypervolemic, hemodilutional) therapy. Three of these patients required mechanical and pharmacologic angioplasty. No surgical complications were incurred as a direct result of the craniotomy. One patient in the endovascular group developed a femoral pseudoaneurysm as a complication of the procedure and postocclusion anticoagulation. No thromboembolic events were noted in this group.

CONCLUSION: In patients with similar Hunt and Hess grades and Fisher grades, preliminary data suggest that the frequency and severity of cerebral vasospasm may be reduced in those treated by endovascular occlusion of their aneurysm as compared with those treated by direct surgical clipping.