Neurointervention · IR Playbook

Endovascular Treatment of Cerebral Vasospasm

Endovascular treatment of cerebral vasospasm is rescue therapy for angiographic large-vessel narrowing after aneurysmal subarachnoid haemorrhage that is producing delayed cerebral ischaemia despite euvolaemia, enteral nimodipine and induced hypertension. It works by two different mechanisms with different durability: intra-arterial vasodilators relax constricted arterial smooth muscle pharmacologically, so dilation is rapid, diffuse, reaches distal vessels the balloon cannot, and reverses as the drug washes out, while transluminal balloon angioplasty mechanically stretches and disrupts the constricted media and adventitial collagen, so dilation is durable but is purchased with a controlled wall injury. Every major complication is predictable from that split — hypotension and raised intracranial pressure from the drug, vessel rupture, dissection and perforator loss from the balloon. Guideline-supported: the 2023 AHA/ASA aneurysmal subarachnoid haemorrhage guideline gives both intra-arterial vasodilator therapy and cerebral angioplasty a Class 2b (B-NR) recommendation in severe vasospasm, and a pooled analysis reports 93% radiological and 65% clinical improvement after balloon angioplasty with 1.5% haemorrhagic and 5% ischaemic complications.

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