Diagnosis and endovascular management of vasospasm after aneurysmal subarachnoid hemorrhage - survey of real-life practices

Adrien Guenego; Robert Fahed; Aymeric Rouchaud; Gregory Walker; Tobias D Faizy; Peter B Sporns; Mohamed Aggour; Pascal Jabbour; Andrea M Alexandre; Pascal John Mosimann; Adam A Dmytriw; Noémie Ligot; Niloufar Sadeghi; Chengbo Dai; Ameer E Hassan; Vitor M Pereira; Justin Singer; Jeremy J Heit; Fabio Silvio Taccone; Michael Chen; Jens Fiehler; Boris Lubicz; Research Committee of the European Society of Minimally Invasive Neurological Therapy (ESMINT)

doi:10.1136/jnis-2023-020544

Diagnosis and endovascular management of vasospasm after aneurysmal subarachnoid hemorrhage - survey of real-life practices

J Neurointerv Surg. 2023 Jul 27:jnis-2023-020544. doi: 10.1136/jnis-2023-020544. Online ahead of print.

Authors

Adrien Guenego¹, Robert Fahed², Aymeric Rouchaud^{3

4}, Gregory Walker^{5

5}, Tobias D Faizy⁶, Peter B Sporns⁷, Mohamed Aggour⁸, Pascal Jabbour⁹, Andrea M Alexandre¹⁰, Pascal John Mosimann¹¹, Adam A Dmytriw^{12

13}, Noémie Ligot¹⁴, Niloufar Sadeghi¹⁵, Chengbo Dai¹⁶, Ameer E Hassan¹⁷, Vitor M Pereira¹³, Justin Singer¹⁸, Jeremy J Heit¹⁹, Fabio Silvio Taccone²⁰, Michael Chen²¹, Jens Fiehler²², Boris Lubicz²³; Research Committee of the European Society of Minimally Invasive Neurological Therapy (ESMINT)

Affiliations

¹ Interventional Neuroradiology Department, Hôpital Erasme - Hôpital Universitaire de Bruxelles (HUB) - Université Libre de Bruxelles (ULB), Bruxelles, Belgium adrienguenego@gmail.com.
² Department of Medicine - Division of Neurology, The Ottawa Hospital - Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada.
³ Interventional neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France.
⁴ Univsersity of Limoges, CNRS, XLIM, UMR 7252, Limoges, France.
⁵ Department of Medicine - Division of Neurology, Royal Columbian Hospital, New Westminster, British Columbia, Canada.
⁶ Radiology, Stanford University School of Medicine, Stanford, California, USA.
⁷ Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.
⁸ Department of Radiology, The Royal London Hospital, London, UK.
⁹ Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹⁰ UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy.
¹¹ Neuroradiology Division, University Medical Imaging TorontoJoint Department of Medical ImagingUniversity Health Networks and University of TorontoToronto Western Hospital, Toronto, Ontario, Canada.
¹² Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
¹³ Neurovascular Centre, Departments of Medical Imaging & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
¹⁴ Department of Neurology, Hôpital Erasme - Hôpital Universitaire de Bruxelles (HUB) - Université Libre de Bruxelles (ULB), Brussels, Belgium.
¹⁵ Department of Radiology and Neuroradiology, Hôpital Erasme - Hôpital Universitaire de Bruxelles (HUB) - Université Libre de Bruxelles (ULB), Brussels, Belgium.
¹⁶ Department of Neurology, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.
¹⁷ Department of Neurology, Valley Baptist Health System Inc, Harlingen, Texas, USA.
¹⁸ Neurosurgery, Spectrum Health Michigan State University College of Human Medicine Internal Medicine Residency Program, Grand Rapids, Michigan, USA.
¹⁹ Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA.
²⁰ Department of Intensive Care, Hospital Erasme, Hôpital Erasme - Hôpital Universitaire de Bruxelles (HUB) - Université Libre de Bruxelles (ULB), Brussels, Belgium.
²¹ Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA.
²² Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
²³ Interventional Neuroradiology Department, Hôpital Erasme - Hôpital Universitaire de Bruxelles (HUB) - Université Libre de Bruxelles (ULB), Bruxelles, Belgium.

PMID: 37500477
DOI: 10.1136/jnis-2023-020544

Abstract

Background: Vasospasm and delayed cerebral ischemia (DCI) are the leading causes of morbidity and mortality after intracranial aneurysmal subarachnoid hemorrhage (aSAH). Vasospasm detection, prevention and management, especially endovascular management varies from center to center and lacks standardization. We aimed to evaluate this variability via an international survey of how neurointerventionalists approach vasospasm diagnosis and endovascular management.

Methods: We designed an anonymous online survey with 100 questions to evaluate practice patterns between December 2021 and September 2022. We contacted endovascular neurosurgeons, neuroradiologists and neurologists via email and via two professional societies - the Society of NeuroInterventional Surgery (SNIS) and the European Society of Minimally Invasive Neurological Therapy (ESMINT). We recorded the physicians' responses to the survey questions.

Results: A total of 201 physicians (25% [50/201] USA and 75% non-USA) completed the survey over 10 months, 42% had >7 years of experience, 92% were male, median age was 40 (IQR 35-46). Both high-volume and low-volume centers were represented. Daily transcranial Doppler was the most common screening method (75%) for vasospasm. In cases of symptomatic vasospasm despite optimal medical management, endovascular treatment was directly considered by 58% of physicians. The most common reason to initiate endovascular treatment was clinical deficits associated with proven vasospasm/DCI in 89%. The choice of endovascular treatment and its efficacy was highly variable. Nimodipine was the most common first-line intra-arterial therapy (40%). Mechanical angioplasty was considered the most effective endovascular treatment by 65% of neurointerventionalists.

Conclusion: Our study highlights the considerable heterogeneity among the neurointerventional community regarding vasospasm diagnosis and endovascular management. Randomized trials and guidelines are needed to improve standard of care, determine optimal management approaches and track outcomes.

Keywords: aneurysm; subarachnoid.