on April 17, 2008
Published online before print April 17, 2008, doi: 10.1161/STROKEAHA.107.502666
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Submitted on September 3, 2007
From the University of California, Davis Medical Center (J.P.M., M.Z.-L., J.H., N.R., D.R., J.D., K.S., L.K.M.), Sacramento; Wayne State University (W.C.), Detroit, Mich; University of Washington–Harborview Medical Center (D.N., J.E.), Seattle; St Elisabeth Ziekenhuis (B.V.), Tilburg, Netherlands; University Medical Center Utrecht(B.V.), Netherlands; University of Florida (R.M.), Gainesville; Vanderbilt University Medical Center (R.M.), Nasville, Tenn; University of Toronto–St Michael's Hospital (A.B.), Canada; Medical College of Virginia (M.R.B.), Richmond. * To whom correspondence should be addressed. E-mail: marike.z.lee{at}gmail.com.
Background and Purpose—Cerebral vasospasm continues to be a major cause of poor outcome in patients with ruptured aneurysms. Prophylactic Transluminal Balloon Angioplasty (pTBA) appeared to prevent delayed ischemic neurological deficit in a pilot study. A phase II multicenter randomized clinical trial was subsequently designed. Methods—One hundred and seventy patients with Fisher Grade III subarachnoid hemorrhage were enrolled in the study. Of these, 85 patients were randomized to the treatment group and underwent pTBA within 96 hours after subarachnoid hemorrhage. Main end points of the study included the 3-month dichotomized Glasgow Outcome Score (GOS), development of delayed ischemic neurological deficit (DIND), occurrence of Transcranial Doppler (TCD) vasospasm, and length of stay in the ICU and hospital. Results—The incidence of DIND was lower in the pTBA group (P=0.30) and fewer patients required therapeutic angioplasty to treat DIND (P=0.03). Overall pTBA resulted in an absolute risk reduction of 5.9% and a relative risk reduction of 10.4% unfavorable outcome (P=0.54). Good grade patients had absolute and relative risk reductions of respectively 9.5 and 29.4% (P=0.73). Length of stay in ICU and hospital was similar in both groups. Four patients had a procedure-related vessel perforation, of which three patients died. Conclusions—While the trial is unsuccessful as defined by the primary end point (GOS), proof of concept is confirmed by these results. Fewer patients tend to develop vasospasm after treatment with pTBA and there is a statistically significantly decreased need for therapeutic angioplasty. pTBA does not improve the poor outcome of patients with Fisher grade III subarachnoid hemorrhage.
Revised on October 1, 2007
Accepted on October 25, 2007
Effect of Prophylactic Transluminal Balloon Angioplasty on Cerebral Vasospasm and Outcome in Patients With Fisher Grade III Subarachnoid Hemorrhage. Results of a Phase II Multicenter, Randomized, Clinical Trial
Marike Zwienenberg-Lee MD*;
Key words: subarachnoid hemorrhage • aneurysm • vasospasm • angioplasty • stenting • outcome • randomized clinical trials