J Cerebrovasc Endovasc Neurosurg.  2023 Sep;25(3):288-296. 10.7461/jcen.2023.E2022.11.005.

The impact of collateral status on cerebral vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage

• Topcu A
• Ozkul A
• Yilmaz A
• Yi HJ
• Shin DS
• Kim B

• KMID: 2546165
• DOI: http://doi.org/10.7461/jcen.2023.E2022.11.005

Abstract

Objective
Cerebral collateral circulation may affect subarachnoid hemorrhage (SAH) induced cerebral vasospasm and delayed cerebral ischemia. In this study our aim was to investigate the relationship between collateral status, vasospasm and delayed cerebral ischemia (DCI) in both aneurysmal and nonaneurysmal SAH.
Methods
Patients diagnosed as SAH with and without aneurysm were included and their data investigated retrospectively. After the patients diagnosed as SAH according to cerebral computed tomography (CT)/magnetic resonance imaging (MRI), they underwent cerebral angiography to check for cerebral aneurysm. The diagnosis of DCI was made according to the neurological examination and control CT/MRI. All the patients had their control cerebral angiography on days 7 to 10 in order to assess vasospasm and also collateral circulation. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System was modified to measure collateral circulation.
Results
A total of 59 patients data were analyzed. Patients with aneurysmal SAH had higher Fisher scores and DCI was more common. Although there was no statistically significant difference between the patients with and without DCI in terms of demographics and mortality, patients with DCI had worse collateral circulation and more severe vasospasm. These patients had higher Fisher scores and more cerebral aneurysm overall.
Conclusions
According to our data, patients with higher Fisher scores, more severe vasospasm, and poor cerebral collateral circulation may experience DCI more frequently. Additionally aneurysmal SAH had higher Fisher scores and DCI was seen more common. To improve the clinical results for SAH patients, we believe that physicians should be aware of the DCI risk factors.

Keyword

Subarachnoid hemorrhage; Vasospasm; Cerebral ischemia; Cerebral circulation; Cerebral collaterals; Aneurysm

Figure

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  Fig. 1. American Society of Neurointerventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System [4].

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  Fig. 2. (A) A cerebral angiography of 43 years old male patient with right MCA M1 coilled aneurysm showing right ACA vasospasm without the presence of collateral arteries (ASITN/SIR Grade 0). (B) There is a significant perfusion deficit in the area of the right ACA in subsequent venous phase. (C) 85 years old female patient with ruptured ACA and MCA aneurysm. (D) Cerebral angiography demonstrates vasospasm of left ACA and MCA with slow-flow leptomeningeal collateral vessels with perfusion deficit (ASITN/ SIR Grade 1). (E) 59 years old female patient with coilled right ICA-ACA A1 ruptured aneurysm. Left ACA vasospasm with rapid left MCA leptomeningeal collaterals (ASITN/SIR Grade 2). (F) Mild perfusion deficit can be seen in the subsequent venous phase. (G) 32 years old male patient with ruptured left MCA bifurcatio aneurysm treated with coil embolization. Cerebral angiography demonstrates a severe vasospasm of MCA with rapid ECA leptomeningeal collateral vessels (ASITN/SIR Grade 3). (H) In late venous phase no associated perfusion deficit is detected. (I) 62 years old male patient with ruptured AcomA aneurysm. (J) The cerebral angiography demonstrates vasospasm of ACA with complete and rapid collaterals of MCA leptomeningeal collateral vessels (ASITN/SIR Grade 3). There is no perfusion defisit in the area of vasospasm. MCA, middle cerebral artery; ACA, anterior cerebral artery; ASITN/SIR, American Society of Neurointerventional and Therapeutic Neuroradiology/ Society of Interventional Radiology; ICA, internal carotid artery; ECA, external carotid artery; AcomA, anterior communicating artery

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  Fig. 3. Angiographic vasospasm grade [10].

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