J Cerebrovasc Endovasc Neurosurg.  2021 Jun;23(2):159-168. 10.7461/jcen.2021.E2020.11.001.

Hybrid microcatheter angioplasty for refractory cerebral vasospasm

Affiliations
  • 1Department of Neurological Surgery Stroke and Applied Neuroscience Center, University of Washington School of Medicine, Seattle, WA, USA
  • 2Convent of the Sacred Heart High School, New York, NY, USA
  • 3Chapman University, Orange, CA, USA
  • 4Iowa State University, Ames, IA, USA
  • 5Departments of Neurological Surgery, Radiology, Mechanical Engineering and Stroke and Applied Neuroscience Center, University of Washington School of Medicine, Seattle, WA, USA

Abstract

Cerebral vasospasm is a significant cause of morbidity and mortality associated with aneurysmal subarachnoid hemorrhage (aSAH). Intra-arterial chemical and mechanical angioplasty, performed alone or in combination, have been shown to ameliorate cerebral vasospasm and improve patient outcomes. Few options exist for patients who fail these traditional endovascular tactics. We propose a hybrid microcatheter technique that combines the mechanical benefit of transient high pressure induced by microcatheter fluid bolus with a low-dose vasodilator infusion. Five patients with moderate to severe symptomatic vasospasm who failed medical and traditional endovascular management were treated using a hybrid microcatheter technique. All angioplasty procedures were technically successful, and the degree of vasospasm improved following angioplasty. There were no complications related to the cerebral angioplasty procedures. None of the patients required repeat endovascular intervention. Hybrid microcatheter angioplasty may be a useful complement to mechanical or pharmacological techniques in the endovascular management of intractable cerebral vasospasm after aSAH.

Keyword

Angioplasty; Endovascular; Microcatheter; Vasospasm; Technique; Hybrid

Figure

  • Fig. 1. Hybrid microcatheter technique. Traditional endovascular interventions for vasospasm include intra-luminal mechanical disruption using a micro-balloon (A) for proximal cerebral vasospasm, or (B) intra-arterial chemical infusion of to treat distal vasospasm. We propose a hybrid microcatheter technique (C) that combines the mechanical benefit of transient high pressure induced by microcatheter fluid bolus with a low-dose vasodilator infusion.

  • Fig. 2. Critical vasospasm. DSA showed severe vasospasm of the right MCA (arrow, A), and ACAs with moderate stenosis of the terminal ICA. Final angiographic runs demonstrated significant improvement in vessel caliber of the MCA (B). DSA, digital subtraction angiography; MCA, middle cerebral artery; ACAs, anterior cerebral arteries; ICA, internal carotid artery.

  • Fig. 3. Contiguous ICAS. The patient was known to have ICAS at baseline, but comparison to prior DSA showed a contiguous area of ICAS with vasospasm (A). Post-hybrid technique, improvement in MCA caliber is noted without disruption of existing plaque in the MCA (arrow, B). ICAS, intracranial atherosclerotic stenosis; DSA, digital subtraction angiography; MCA, middle cerebral artery.

  • Fig. 4. Sharp Vessel Angle. DSA showed severe in the left ACA (arrow, A), which provided supply to both ACA territories. Final angiographic runs demonstrated significant improvement in vessel caliber of the A1 segment (B). DSA, digital subtraction angiography; ACA, anterior cerebral artery.

  • Fig. 5. Spanning the bifurcation. DSA confirmed severe vasospasm at the right terminal ICA and MCA with spasm spanning the MCA bifurcation (arrow, A). Final angiographic runs demonstrated improvement in vessel caliber of the M1 segment but persistent narrowing of distal vessel caliber (B). DSA, digital subtraction angiography; ICA, internal carotid artery; MCA, middle cerebral artery.

  • Fig. 6. Adjacent aneurysm. DSA demonstrated vasospasm of the left MCA M1 and M2 segments (A), along with an unsecured unruptured aneurysm (arrow, B) at the MCA trifurcation. Post-angiographic views showed improvement in M1 segment vessel caliber (B). DSA, digital subtraction angiography; MCA, middle cerebral artery.


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