Transluminal balloon angioplasty improves brain tissue oxygenation and metabolism in severe vasospasm after aneurysmal subarachnoid hemorrhage: Case report

OBJECTIVE AND IMPORTANCE: The effect of transluminal balloon angioplasty on cerebral biochemical monitoring during treatment of severe cerebral vasospasm after subarachnoid hemorrhage (SAH) was investigated. CLINICAL PRESENTATION: In a 36-year-old man, an anterior communicating artery aneurysm caused an SAH (Hunt and Hess Grade IV, Fisher Grade III). After clipping, intraparenchymal monitoring (intracranial pressure, brain tissue oxygen tension [P_tiO₂], and microdialysis sampling of extracellular glucose, lactate, pyruvate, and glutamate) was initiated. Flow velocities obtained by transcranial Doppler sonography increased in the internal carotid artery (ICA)/middle cerebral artery bilaterally. INTERVENTION: After a decrease of P_tiO₂ to less than 2 mm Hg and an increase of the lactate-to-pyruvate ratio to 44 in the territorial region of the left ICA, angiography demonstrated a 70 to 80% stenosis of the left ICA, which was dilated by a temporary occlusion balloon. This maneuver normalized the ICA diameter, P_tiO₂ increased immediately from 1.5 to 40 mm Hg, the lactate-to-pyruvate ratio decreased from 44 to 30, and extracellular glucose increased from 0.4 to 0.9 mmol/L. No major changes in glutamate or intracranial pressure were seen. In the clinical follow-up, the patient showed a good recovery 6 months after SAH. CONCLUSION: Transluminal balloon angioplasty led to a continuous and effective resolution of cerebral vasospasm observed by sustained, improved cerebral biochemical parameters. Both P_tiO₂ and lactate-to-pyruvate ratio might provide an early diagnosis of severe cerebral vasospasm after SAH and continuous surveillance of threatened tissue regions after transluminal balloon angioplasty.