Multimodality therapy for cerebral vasospasm after SAH: Importance of intensive care and intraarterial injection of fasudil hydrochloride

Until now, no absolute therapy for cerebral vasospasm (VS) after subarachnoid haemorrhage (SAH) has been established. Here we examine the efficacy of intensive multimodality therapy, contrasting with the treatment in the non-multimodality period in our institute. For 10 years, a total of 108 patients who suffered subarachnoid haemorrhage (SAH) were divided into two groups. Group A patients are from a period of time when there was no particular standardized protocol for treating SAH, i.e. 1996-2000. Group B patients include the intensive care group for treating SAH, and we employed multimodality therapy on Group B by using intraventricular urokinase (UK) injection, lumbar (LD) or cisternal drainages (CD) and timely intraarterial fasudil hydrochloride (FH) injection in the second half of the period with a standardized protocol. Urokinase was given as a bolus administration from a ventricular drain 12 h after surgery, and prophylactic mild hypertension and normovolemia were strictly performed. If symptomatic spasm were detected, immediate intraarterial FH injection or percutaneous transluminal angioplasty was performed. Angiographic and symptomatic vasospasm and the Glasgow outcome scale score 3 months post SAH were evaluated. Angiographic vasospasm occurred in 64.2% and 59% in groups A and B, respectively. Symptomatic vasospasm was observed in 56.5% of Group A and 37.1% of Group B. There was a statistical significance between the percentages of symptomatic vasospasm in Groups A and B (p = 0.0422), but no significant differences were seen in angiographic vasospasm between these 2 groups. As for the outcome, 25.7% of Group A and 10.8% of Group B were poor outcome, and statistical significance (p = 0.001) was seen between these two groups. It is worth noting that there were no deaths due to vasospasm in Group B, in contrast to the 14.8% death rate in Group A. Introduction of multimodality therapy was effective to prevent symptomatic vasospasm and improved the patients' outcome.