PMC3115198_01
(a) CT scans showing SAH combined with a massive right temporal intracerebral hematoma. (b) Preoperative 3-dimensional CT angiography showing bilateral MCA aneurysms. Ruptured aneurysm on the right side (arrow) was successfully clipped (inset). Clinical deterioration attributable to vasospasm was suspected based on findings of no apparent ischemic lesion on diffusion-weighted MR images (c) and relatively decreased rCBF in the left ACA and MCA territories on Tc-99 m HMPAO SPECT (d)
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A computed tomography (CT) scan revealed diffuse thick SAH combined with a large right temporal intracerebral hematoma [Figure 1a], and a ruptured right middle cerebral artery aneurysm [Figure 1b] was successfully clipped following extensive hematoma evacuation by emergent surgery performed at 6 hours after SAH onset. HMPAO SPECT) revealed a mild reduction in rCBF in the left anterior cerebral artery (ACA) and MCA territories Figure 1d] indicative of clinical deterioration attributable to vasospasm. Hyperdynamic therapy with dobutamine (initial dose: 3 mug/kg/min; increased in 3 mug/kg/min increments every 4 hours to a level at which the deterioration resolved) combined with mild hypervolemia with supplemental low-molecular-weight dextran (500 mL/day) was initiated.
(a) Left internal carotid artery angiogram demonstrates diffuse angiographic vasospasm. (b) Intra-arterial fasudil infusion from the top of internal carotid artery (arrow) and subsequent selective infusion from distal portion of M1 (c, arrow), resulting in significant reversal of vasospasm (d). Low and fluctuating rSO2 detected in the left ACA territory (E, Ch-1) increased immediately after each fasudil infusion, while rSO2 in the MCA territory (F, Ch-3) gradually elevated following infusion from the distal M1 segment. Each yellow bar represents intra-arterial fasudil infusion
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A1 segment of the left ACA and of the proximal left A2 and M2 segments and diffuse spasm in their branches [Figure 2a]. After systemic heparinization, a 5-Fr. guiding catheter was advanced to the cervical portion of the internal carotid artery and a microcatheter was placed at the top of the internal carotid artery[Figure 2b], Arrow] and fasudil hydrochloride (25 mg) was infused at a rate of 1.0 mg/mL (consisting of 60 mg of fasudil hydrochloride mixed in 60 mL of normal saline) for distribution into both the ACA and MCA territories, resulting in significant reversal of vasospasm in distal A1 and M1 segments [Figure 2c] and improvement of cerebral circulation time (as measured by the interval between the first image in which contrast is visible above the supraclinoid internal carotid artery and the peak filling of the cortical parietal veins) from 6.6 to 5.3 seconds. Since focal severe vasospasm still existed in the distal potion of M3 (superior division), superselective infusion of fasudil (25 mg) into the MCA distribution was performed by directing the microcatheter into the distal portion of M1 [Figure 2c, arrow]. Although further dilation could not be obtained in the M3 segment, good angiographic results were obtained in the remaining spastic vessels [Figure 2d]. The intra-arterial fasudil likewise produced improvement of low and fluctuating rSO2 in the left ACA--MCA territory immediately after onset of each infusion[Figure 2e, Ch-1], and the left MCA territory flow then gradually increased following superselective infusion in the distal M1 segment[Figure 2f, Ch-3].
Diffusion-weighted MR images (a) and SPECT (b) showing new small infarctions and decreased rCBF in the left ACA--MCA territory. (c) DSA showing moderate vasospasm of distal A1 and diffuse vasospasm in the distal ACA and MCA branches. (d) Intra-arterial fasudil infusions resulted in an improvement of the distal vasospasm and cerebral circulation time (inset). Low and fluctuating rSO2 detected in the left ACA--MCA territories increased immediately after each infusion and recovered close to the contralateral recordings (e, Ch-1). Each yellow bar represents intra-arterial fasudil infusion
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The intra-arterial fasudil likewise produced improvement of low and fluctuating rSO2 in the left ACA--MCA territory immediately after onset of each infusion[Figure 2e, Ch-1], and the left MCA territory flow then gradually increased following superselective infusion in the distal M1 segment[Figure 2f, Ch-3]. Diffusion-weighted MR imaging revealed small hyperintense signals in the left insular cortex and medial frontal cortex [Figure 3a]. Tc-99 m HMPAO SPECT detected decreased rCBF in the left ACA and MCA territories, in contrast to hyperperfusion observed in the superior trunk of the left MCA territory [Figure 3b. Repeated DSA demonstrated moderate vasospasm of the distal A1 and diffuse vasospasm in the distal ACA and MCA branches as well as persistent focal spasm in the distal potion of the M3 segment [Figure 3c]. Then intra-arterial fasudil infusions (25 mg/each) were performed again, resulting in improvement of the distal vasospasm and cerebral circulation time[Figure 3c d, inset] from 5.8 to 4.9 seconds. In response to intra-arterial fasudil infusions, rSO2 in the left ACA--MCA territory rapidly increased to a level close to that on the contralateral side [Figure 3e].
(a) Follow-up MR angiography on day 14 showing improvement of vasospasm. (b) Diffusion-weighted MR images demonstrated no additional ischemic findings after repeated endovascular therapy. (c) Tc-99 m HMPAO SPECT confirmed normalized rCBF distribution in the left hemisphere. (d) CT scan at 2 months after SAH showing no apparent ischemia in the left hemisphere
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Follow-up MR angiography on day 14 (corresponding to 3 days after the second endovascular therapy) confirmed improvement of vasospasm [Figure 4a]. Diffusion-weighted MR imaging revealed no additional ischemic findings after repeated endovascular therapy [Figure 4b]. Abnormal rCBF distributions in the left hemisphere were also normalized [Figure 4c]. The patient underwent ventriculoperitoneal shunt placement on day 30 for the treatment of post-SAH normal pressure hydrocephalus [Figure 4d], resulting in favorable functional outcome with a modified Rankin Scale score of 1 at 2 months.