A Perspective on Cerebral Vasospasm Post Aneurysmal Subarachnoid Hemorrhage: Synopsis, Guidelines, Treatment, & Advances

Abstract

Sajal Kulhari*

Cerebral vasospasm is a serious complication that occurs after Aneurysmal Subarachnoid Hemorrhage (ASAH), affecting approximately one-third of patients with ASAH. It can lead to Delayed Cerebral Infarction (DCI), resulting in high mortality and severe disability. Current guidelines recommend a combination of proximal cerebral vessel balloon angioplasty and intra-arterial vasodilators or solely the use of intra-arterial vasodilators for treating cerebral vasospasm. However, distal balloon angioplasty is not recommended due to its associated risks, such as arterial rupture. DCI, often caused by cerebral vasospasm, can be diagnosed clinically or radiologically. Treatment aims to prevent DCI and includes the administration of Nimodipine, maintaining euvolemia, and stabilizing blood pressure. In cases where standard management fails, endovascular rescue interventions can be considered, such as endovascular vasodilators and spasmolytics, as well as mechanical angioplasty. Some previous treatments, including statin therapy and magnesium sulfate, have shown limited benefit in treating cerebral vasospasm. Prophylactic treatments for cerebral vasospasm have been explored but are not yet supported by guidelines, as they have shown increased risks without clear benefits. Recent developments have focused on technological advances in balloon and stent technology. Newer balloons, such as the Scepter XC balloon, have demonstrated efficacy in treating vasospasm in both proximal and distal vessels. Improved navigation, lower rates of rupture, and increased success rates have been observed. Stent-retrievers have also shown promise in dilating cerebral vessels without occlusion, resulting in improved vessel diameter, blood flow, and neurological outcomes. The emerging theme in post ASAH cerebral vasospasm treatment is the advancement of balloons and stents, enabling safer and more effective treatment of distal vessel vasospasm. These advancements offer potential solutions for cases that are refractory to standard therapies and show promise in improving patient outcomes.