Perspectives Commentary on: Results of an International Survey on the Investigation and Endovascular Management of Cerebral Vasospasm and Delayed Cerebral Ischemia by Hollingworth et al. World Neurosurg 83: 1120-1126.E1, 2015
Toward a Better Understanding of Vasospasm and Delayed Cerebral Ischemia Felipe C. Albuquerque
n a paper recently published in WORLD NEUROSURGERY, Hollingworth et al. report the results of an international survey on endovascular management of vasospasm and delayed cerebral ischemia. As the authors point out, vasospasm and its sequelae remain vexing dilemmas in contemporary neurosurgical practice. Despite advances in understanding and treatment, a substantial percentage of patients with subarachnoid hemorrhage eventually have a stroke or even die because of vasospasm or delayed cerebral ischemia (1, 2).
In an effort to elucidate common screening and endovascular treatment practices, the authors created a 13-question survey submitted to members of U.S. and international neurosurgical and neuroradiologic societies. The results demonstrate wide variability in how vasospasm is diagnosed and treated. The authors used the results of this survey to design the Intra-arterial Vasospasm Trial (ClinicalTrials.gov Identifier: NCT01996436), a multicenter U.S. trial that will assess the efficacy of various intra-arterially administered medications. The scientific methodology—specifically, screening the commonly used treatment modalities and then scrutinizing them through comparative, randomized analysis—is integral to the development of evidencebased medical practices. The survey results indicate significant disparities in the diagnosis and management of vasospasm in the United States and abroad. These results are influenced by demographic and socioeconomic factors and confirm our inconsistent knowledge of the disease and its treatment. Nonetheless, certain generalities were elucidated by the survey findings. Specifically, when the diagnosis of
Key words Angioplasty - Cerebral vasospasm - Delayed cerebral ischemia - Intra-arterial treatment - Subarachnoid hemorrhage - Survey - Transcranial Doppler -
WORLD NEUROSURGERY 84 : 623-624, SEPTEMBER 2015
vasospasm is confirmed, optimal medical therapy is often initiated before endovascular treatment is considered. Endovascular management, consisting of the transarterial delivery of medications and angioplasty, is widely accepted as the next line of treatment, although discrepancies were discovered concerning the specific medications used and the timing of angioplasty. By ascertaining the commonly employed methods of treatment, the authors have created a platform for the development of additional clinical trials. However, an important caveat is that endovascular treatment is only 1 part of the entire management paradigm. The validity of any randomized analysis of the efficacy of specific endovascular methods is predicated on the standardization of the initial medical therapeutic stage of management and the treatment protocol undertaken after endovascular therapy. Eliminating these crucial variables would facilitate the objective analysis of specific endovascular treatments. Although the authors should be congratulated for elucidating the inconsistencies in the endovascular management of vasospasm and calling for additional clinical trials, the central issue remains our incomplete understanding of this pathology. The transarterial delivery of vasodilatory agents, an inherently rational approach to vasospasm, is nonetheless scientifically unproven. Furthermore, although the durability of angioplasty is well recognized, a casecontrol analysis of its risks and long-term benefits is lacking. The continued scientific investigation of the etiology and prevention of vasospasm is as important as the rigorous examination of these endovascular techniques. These studies will form the basis of future therapeutic trials.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, USA To whom correspondence should be addressed: Felipe C. Albuquerque, M.D. [E-mail: [email protected]
] Citation: World Neurosurg. (2015) 84, 3:623-624. http://dx.doi.org/10.1016/j.wneu.2015.04.009
REFERENCES 1. Dorsch N: A clinical review of cerebral vasospasm and delayed ischaemia following aneurysm rupture. Acta Neurochir Suppl 110:5-6, 2011.
2. Macdonald RL: Delayed neurological deterioration after subarachnoid haemorrhage. Nat Rev Neurol 10:44-58, 2014. Citation: World Neurosurg. (2015) 84, 3:623-624. http://dx.doi.org/10.1016/j.wneu.2015.04.009
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Photo by Marin F. Stancic, a spinal surgeon with a neurosurgical background working at the University of Zagreb School of Medicine in Zagreb, Croatia. “Marina in Split, Croatia taken with Hasselblad 500 C/M from my gaeta “Santiago.” Split, Croatia
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2015.04.009