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CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2022; 41(01): e58-e69
DOI: 10.1055/s-0041-1740196
Review Article

Chemical Angioplasty with Nitroglycerin for Vasospasm after Subarachnoid Hemorrhage: Case Series and Review

Angioplastia química com nitroglicerina para vasoespasmo após hemorragia subaracnóide: Série de casos e revisão
Luana Antunes Maranha Gatto 
1   Neurosurgeon and Interventional Neuroradiologist, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
,
Bruno Henrique Dallo Gallo 
2   Academic of Medicine, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
,
Gelson Luis Koppe 
3   Interventional Neuroradiology Department, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
,
Zeferino Demartini  Junior
1   Neurosurgeon and Interventional Neuroradiologist, Hospital Universitário Cajuru, Pontifícia Universidade Católica do Paraná, Curitiba, PR, Brazil
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Abstract

Introduction Vasospasm is a common and potentially devastating complication in patients with subarachnoid hemorrhage, causing high morbidity and mortality. There is no effective and consistent way to prevent or treat cerebral vasospasm capable of altering the morbidity and mortality of this complication. Animal and human studies have attempted to show improvement in aneurysmal vasospasm. Some sought their prevention; others, the treatment of already installed vasospasm. Some achieved only angiographic improvement without clinical correlation, others achieved both, but with ephemeral duration or at the expense of very harmful associated effects. Endovascular techniques allow immediate and aggressive treatment of cerebral vasospasm and include methods such as mechanical and chemical angioplasty. These methods have risks and benefits.

Objectives To analyze the results of chemical angioplasty using nitroglycerin (GTN). In addition, to perform a comprehensive review and analysis of aneurysmal vasospasm.

Methods We describe our series of 77 patients treated for 8 years with angioplasty for vasospasm, either mechanical (with balloon), chemical (with GTN) or both.

Results Eleven patients received only balloon; 37 received only GTN; 29 received both. Forty-four patients (70.1%) evolved with delayed cerebral ischemia and 19 died (mortality of 24.7%). Two deaths were causally related to the rupture of the vessel by the balloon. The only predictors of poor outcome were the need for external ventricular drainage in the first hours of admission, and isolated mechanical angioplasty.

Conclusions Balloon angioplasty has excellent results, but it is restricted to proximal vessels and is not without complications. Chemical angioplasty using nitroglycerin has reasonable but short-lived results and further research is needed about it. It is restricted to vasospasm angioplasties only in hospitals, like ours, where better and more potent vasodilator agents are not available.

Resumo

Introdução O vasoespasmo é uma complicação comum e potencialmente devastadora em pacientes com hemorragia subaracnóidea, resultando em alta morbimortalidade. Não existe uma forma eficaz e consistente de prevenir ou tratar o vasoespasmo cerebral capaz de alterar significativamente a morbidade e mortalidade desta complicação. Estudos em animais e humanos tentaram mostrar melhora no vasoespasmo aneurismático. Alguns buscaram sua prevenção; outros, o tratamento de vasoespasmo já instalado. Alguns conseguiram apenas melhora angiográfica sem correlação clínica, outros conseguiram ambos, mas com duração efêmera ou às custas de efeitos colaterais muito deletérios. As técnicas endovasculares permitem o tratamento imediato e agressivo do vasoespasmo cerebral e incluem métodos como a angioplastia mecânica e química. Estes métodos apresentam riscos e benefícios.

Objetivos Analisar os resultados da angioplastia química utilizando nitroglicerina (GTN). Além disso, fazer uma revisão e análise global acerca do vasoespasmo aneurismático.

Métodos Descrevemos nossa série de 77 pacientes tratados por 8 anos com angioplastia para vasoespasmo, seja mecânica (com balão), química (com GTN), ou ambas.

Resultados Onze pacientes receberam apenas balão; 37 receberam apenas GTN; 29 receberam ambos. Um total de 44 pacientes (70,1%) evoluíram com isquemia cerebral tardia e 19 faleceram (mortalidade de 24,7%). Dois óbitos foram diretamente relacionados à ruptura do vaso pelo balão. Os únicos fatores preditores de mau resultado foram a necessidade de drenagem ventricular externa nas primeiras horas de admissão e a angioplastia mecânica isolada.

Conclusões A angioplastia com balão tem excelentes resultados, mas é restrita a vasos proximais e não é isenta de complicações. A GTN possui resultados razoáveis, porém efêmeros, e mais pesquisas são necessárias. Fica restrita para as angioplastias por vasoespasmo apenas a hospitais, como o nosso, nos quais não há disponibilidade de agentes vasodilatadores melhores e mais potentes.

Keywords

intracranial vasospasm - balloon angioplasty - nitroglycerin - aneurysmal subarachnoid hemorrhage - cerebral hemorrhage - vasodilator agents

Palavras-chave

vasoespasmo intracraniano - angioplastia com balão - nitroglicerina - hemorragia subaracnóidea aneurismática - hemorragia cerebral - agentes vasodilatadores


Publikationsverlauf

Eingereicht: 27. Februar 2021

Angenommen: 30. Juli 2021

Artikel online veröffentlicht:
13. Januar 2022

© 2022. Sociedade Brasileira de Neurocirurgia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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