Early Vasospasm after Aneurysmal Subarachnoid Hemorrhage Predicts the Occurrence and Severity of Symptomatic Vasospasm and Delayed Cerebral Ischemia

Background: Cerebral vasospasm usually develops several days after subarachnoid hemorrhage (SAH) and is generally acknowledged as a strong outcome predictor. In contrast, much less is known about the nature and eventual consequences of early angiographic vasospasm (EAVS) seen on admission digital subtraction angiography (DSA). Therefore, we aimed at identifying the risk factors and clinical impact of EAVS after SAH. Methods: Five hundred and thirty-one SAH patients with admission DSA performed within 72 h after the bleeding event were selected from a comprehensive database containing all consecutive SAH patients treated at our institution between January 2005 and December 2012. Predictors of EAVS, as well as associations between EAVS and delayed vasospasm-related complications, and unfavorable outcome (defined as modified Rankin scale >3) were evaluated in univariate and multivariate analyses. Results: EAVS was seen on 60 DSAs (11.3%) and was independently correlated with delayed symptomatic vasospasm requiring intra-arterial spasmolysis (OR 5.24, p < 0.0001), angioplasty (OR 2.56, p = 0.015) and repetitive endovascular treatment (OR 4.71, p < 0.0001). EAVS also increased the risk for multiple versus single territorial infarction on the follow-up CT scan(s) (OR 2.04, p = 0.047) and independently predicted unfavorable outcome (OR 2.93, p = 0.008). The presence of radiographic signs suspicious for fibromuscular dysplasia were independently associated with the occurrence of EAVS (OR 2.98, p = 0.026) and the need for repetitive endovascular vasospasm treatment (OR 3.95, p = 0.019). Conclusions: In view of the strong correlation with delayed symptomatic vasospasm and its ischemic complications, EAVS can be considered an alerting signal for severe symptomatic vasospasm. Therefore, more attention should be paid to the presence of EAVS on admission DSA.

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Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage

Neurology ◽

10.1212/wnl.0000000000007501 ◽

2019 ◽

Vol 92 (20) ◽

pp. e2385-e2394 ◽

Cited By ~ 2

Author(s):

Cody L. Nesvick ◽

Soliman Oushy ◽

Lorenzo Rinaldo ◽

Eelco F. Wijdicks ◽

Giuseppe Lanzino ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Confidence Interval ◽

Ventriculoperitoneal Shunt ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Tertiary Referral Center ◽

Short And Long Term ◽

Csf Diversion

ObjectiveTo define the in-hospital course, complications, short- and long-term functional outcomes of patients with angiographically negative subarachnoid hemorrhage (anSAH), particularly those with aneurysmal-pattern anSAH (aanSAH).MethodsRetrospective cohort study of patients with aneurysmal subarachnoid hemorrhage (aSAH), aanSAH, and perimesencephalic-pattern anSAH (panSAH) treated at a single tertiary referral center between January 2006 and April 2018. Ninety-nine patients with anSAH (33 aanSAH and 66 panSAH) and 464 patients with aSAH were included in this study. Outcomes included symptomatic hydrocephalus requiring CSF drainage, need for ventriculoperitoneal shunt, radiographic vasospasm, delayed cerebral ischemia (DCI), radiographic infarction, disability level within 1 year of ictus, and at last clinical follow-up as defined by the modified Rankin Scale.ResultsPatients with aanSAH and panSAH had similar rates of DCI and radiologic infarction, and patients with aanSAH had significantly lower rates compared to aSAH (p ≤ 0.018). Patients with aanSAH were more likely than those with panSAH to require temporary CSF diversion and ventriculoperitoneal shunt (p ≤ 0.03), with similar rates to those seen in aSAH. Only one patient with anSAH died in the hospital. Compared to those with aSAH, patients with aanSAH were significantly less likely to have a poor functional outcome within 1 year of ictus (odds ratio 0.26, 95% confidence interval 0.090–0.75) and at last follow-up (hazard ratio 0.30, 95% confidence interval 0.19–0.49, p = 0.002).ConclusionsDCI is very uncommon in anSAH, but patients with aanSAH have a similar need for short- and long-term CSF diversion to patients with aSAH. Nevertheless, patients with aanSAH have significantly better short- and long-term outcomes.

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Abstract W MP39: SSRI/SNRI Use Is Not Associated With Increased Risk Of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.46.suppl_1.wmp39 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Jimmy Young ◽

Tarun Singh ◽

Jennifer Fugate ◽

Alejandro Rabinstein

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Reuptake Inhibitor ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Multivariate Logistic Regression Analysis ◽

Fisher Score ◽

Symptomatic Vasospasm ◽

Increased Risk ◽

Norepinephrine Reuptake Inhibitor

Objective: To determine the effect of Selective Serotonin Reuptake Inhibitor (SSRI)/Selective Norepinephrine Reuptake Inhibitor (SNRI) use prior to or during admission for aneurysmal subarachnoid hemorrhage (aSAH) on the risk of symptomatic vasospasm and diffuse cerebral ischemia (DCI). Methods: Review of electronic records at Mayo Clinic, Rochester from Jan. 2001 to Dec. 2013 of consecutive patients with aSAH. The variables collected and analyzed were: age, sex, active smoking, transfusion, modified Fisher score, WFNS grade, and outcome at discharge. Multivariate logistic regression analysis was used to evaluate factors associated with DCI, symptomatic vasospasm, and poor outcome (modified Rankin score 3-6) within 1 year. Results: 583 [females 367 (63%)] patients with a median age of 55 (47-65) years were admitted with aSAH during the study period. WFNS at nadir was IV-V in 243 (41.6%) and modified Fisher score was 3-4 in 438 (75.2%). Eighty one (14.6%) patients were taking SSRI or SNRI prior to admission and these medications were continued in all of them. Symptomatic vasospasm was present in 154 (27.7%), radiological infarction in 172(29.5%), and DCI in 250(42.9%) patients. SSRI/SNRI use was not associated with the occurrence of DCI (p=0.458), symptomatic vasospasm (p=0.097), radiological infarction (p=0.972), or poor functional outcome (p=0.376). Conclusions: The use of SSRI/SNRI prior to admission and/or during hospitalization in patients with aSAH was not associated with symptomatic vasospasm or DCI.

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Short-Term Antifibrinolytic Therapy Before Early Aneurysm Treatment in Subarachnoid Hemorrhage: Effects on Rehemorrhage, Cerebral Ischemia, and Hydrocephalus

Neurosurgery ◽

10.1227/neu.0b013e3181ebaa36 ◽

2010 ◽

Vol 67 (4) ◽

pp. 935-940 ◽

Cited By ~ 46

Author(s):

Mark R Harrigan ◽

Kiran F Rajneesh ◽

Agnieszka A Ardelt ◽

Winfield S Fisher

Keyword(s):

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Aminocaproic Acid ◽

Neurological Deficits ◽

Short Term ◽

Symptomatic Vasospasm ◽

Term Administration ◽

Ischemic Complications

Abstract BACKGROUND: Long-term administration of the antifibrinolytic agent epsilon aminocaproic acid (EACA) reduces the rate of rehemorrhage in patients with aneurysmal subarachnoid hemorrhage (SAH), but is associated with cerebral ischemia. OBJECTIVE: To evaluate short-term administration of EACA before early surgery in patients with SAH. METHODS: Retrospective review of 356 patients admitted between June 2002 and December 2007 with a diagnosis of aneurysmal SAH. Medical records were reviewed to determine SAH risk factors, clinical grade at the time of admission, and incidence of rehemorrhage, permanent new-onset focal neurological deficits, computed tomography evidence of cerebral infarction, symptomatic vasospasm, and hydrocephalus. RESULTS: Patients underwent treatment of the ruptured aneurysm an average of 47.4 hours after admission and received an average total dose of 40.6 g of EACA. The mean length of time of administration of EACA was 35.6 hours. There was a total of 5 rehemorrhages, for an overall rebleeding rate of 1.4% and a rate of rehemorrhage per 24-hour period of 0.71%. Overall, the rates of symptomatic vasospasm and permanent neurological deficits attributable to ischemic stroke were 11.5% and 7.2%, respectively, and the incidence of shunt-dependent hydrocephalus was 42.3%. Patients who were treated with coiling had higher rates of symptomatic vasospasm and ischemic complications than patients who had surgery. CONCLUSION: Short-term administration of EACA is associated with rates of rehemorrhage, ischemic stroke, and symptomatic vasospasm that compare favorably with historical controls. The rate of hydrocephalus is relatively high and may be attributable to EACA treatment.

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Symptomatic vasospasm and outcomes following aneurysmal subarachnoid hemorrhage: a comparison between surgical repair and endovascular coil occlusion

Journal of Neurosurgery ◽

10.3171/jns.2003.98.2.0319 ◽

2003 ◽

Vol 98 (2) ◽

pp. 319-325 ◽

Cited By ~ 120

Author(s):

Alejandro A. Rabinstein ◽

Mark A. Pichelmann ◽

Jonathan A. Friedman ◽

David G. Piepgras ◽

Douglas A. Nichols ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Content Type ◽

Acute Hydrocephalus ◽

Treatment Groups ◽

Symptomatic Vasospasm ◽

Coil Occlusion ◽

Clip Application ◽

Fine Print

Object. The authors studied patients with aneurysmal subarachnoid hemorrhage (SAH) to determine whether the incidence of symptomatic vasospasm or overall clinical outcomes differed between patients treated with craniotomy and clip application and those treated by endovascular coil occlusion. Methods. The authors reviewed 415 consecutive patients with aneurysmal SAH who had been treated with either craniotomy and clip application or endovascular coil occlusion at a single institution between 1990 and 2000. Three hundred thirty-nine patients underwent surgical clip application procedures, whereas 76 patients underwent endovascular coil occlusion. Symptomatic vasospasm occurred in 39% of patients treated with clip application, 30% of patients treated with endovascular coil occlusion, and 37% of patients overall. Compared with patients treated with clip application, patients treated with endovascular coil occlusion were more likely to suffer acute hydrocephalus (50 compared with 34%, p = 0.008) and were more likely to harbor aneurysms in the posterior circulation (53 compared with 20%, p < 0.001). Logistic regression models controlling for patient age, admission World Federation of Neurosurgical Societies (WFNS) grade, acute hydrocephalus, aneurysm location, and day of treatment revealed that, among patients with an admission WFNS grade of I to III, endovascular coil occlusion carried a lower risk of symptomatic vasospasm (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14—0.8) and death or permanent neurological deficit due to vasospasm (OR 0.28, 95% CI 0.08–1) compared with craniotomy and clip application. Similar models revealed no difference in the likelihood of a Glasgow Outcome Scale score of 3 or less at the longest follow-up review (median 6 months) between treatment groups (OR 0.58, 95% CI 0.28–1.21). Conclusions. Patients with better clinical grades (WFNS Grades I–III) at hospital admission were less likely to suffer symptomatic vasospasm when treated by endovascular coil occlusion, compared with craniotomy and clip application. Nevertheless, there was no significant difference in overall outcome at the longest follow-up examination between the two treatment groups.

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Dual antiplatelet treatment associated with reduced risk of symptomatic vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

Journal of Cerebrovascular and Endovascular Neurosurgery ◽

10.7461/jcen.2020.22.3.134 ◽

2020 ◽

Vol 22 (3) ◽

pp. 134-140

Author(s):

Gyeong-Ung Sun ◽

Eunsung Park ◽

Dae-Won Kim ◽

Sung-Don Kang

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Antiplatelet Treatment ◽

Symptomatic Vasospasm ◽

Reduced Risk ◽

Dual Antiplatelet Treatment

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Abstract TP456: Coated-platelets Levels After Subarachnoid Hemorrhage Predict Post-discharge Short-term Cognitive Outcome

Stroke ◽

10.1161/str.47.suppl_1.tp456 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Bappaditya Ray ◽

Vijay M Pandav ◽

Eleanor A Mathews ◽

David M Thompson ◽

Aminata A Traore ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Acute Phase ◽

Delayed Cerebral Ischemia ◽

Cognitive Outcome ◽

Short Term ◽

Post Discharge ◽

Acute Hospitalization ◽

Symptomatic Vasospasm

Introduction: Delayed cerebral ischemia (DCI) is a determinant of short-term and long-term morbidity after subarachnoid hemorrhage (SAH). DCI is likely due to neurohumoral activation and inflammation-thrombosis cross-talk during the acute phase. Coated-platelets (CP), a subset of procoagulant platelets, contribute to systemic thrombogenicity and are associated with recurrent ischemic stroke. Hypothesis: We hypothesized that high CP levels during first 3 weeks of SAH (acute hospitalization) would be associated with worse short-term clinical outcome. Methods: A prospective cohort of 28 patients with post-discharge clinical follow-up (average 12 weeks) was studied. Outcomes were assessed using modified Rankin Scale (mRS) and Montreal Cognitive Outcome Assessment (MOCA). Blood samples to measure CP levels were performed - 1) during acute hospitalization and 2) at follow-up visit (defined as patient’s baseline). Trend of CP during acute hospitalization was analyzed against weighted mean baseline CP level to test hypothesis. Results: Average age of cohort was 52.6±12.2 years with 71.5% women. During acute phase 9 (32.1%) patients developed symptomatic vasospasm and 14 (50%) had DCI on imaging. Baseline CP levels did not differ (p=0.118) between patients with MOCA ≥26 (41.3%, n=13) and MOCA <26 (29.5%, n=15). However, patients with MOCA <26 had significantly higher CP levels during first 5 days than baseline (50.4% vs 29.5%, p=0.0004). These levels decreased by 1.77%/day from 6-21 days as compared to 1.55%/day for patients with MOCA ≥26 (p=0.723). In contrast, 20 (71.4%) patients with mRS 0-2 had average baseline CP levels of 37.3% vs 8 (28.6%) with mRS 3-6 having CP levels of 31.7%. For patients with mRS 0-2 and mRS 3-6, CP levels increased from baseline during first 5 days after SAH by 10.3% and 16.5% respectively (not statistically significant). Rate of CP decrease during 6-21 days was 1.43%/day and 2.02%/day (p=0.259) for mRS 0-2 and mRS 3-6 respectively. Conclusion: Elevated CP levels during the acute phase of SAH are strongly associated with lower MOCA scores at 12 weeks but not with higher mRS assessment. These results suggest that increased thrombogenicity after SAH leads to cognitive impairment despite good physical outcomes.

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Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device

Interventional Neuroradiology ◽

10.1177/1591019920945554 ◽

2020 ◽

Vol 26 (5) ◽

pp. 582-585

Author(s):

Clint A Badger ◽

Brian T Jankowitz ◽

Hamza A Shaikh

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Coil Embolization ◽

Delayed Cerebral Ischemia ◽

High Morbidity ◽

Symptomatic Vasospasm ◽

Angiographic Vasospasm ◽

Neurologic Function ◽

The Right

Delayed cerebral ischemia due to vasospasm following subarachnoid hemorrhage continues to have high morbidity and mortality despite current treatments. This report highlights the use of the Comaneci (Rapid Medical, Yokneam, Israel), a device FDA approved for temporary coil embolization assistance, for the treatment of symptomatic vasospasm. Ten days post subarachnoid hemorrhage, a patient developed acute left-sided hemiparesis with angiographic vasospasm. Through a Headway 17 microcatheter, a Comaneci 17 was deployed in the right ICA terminus, M1, M2, A1, and, A2 segments resulting in improvement of angiographic vasospasm and the patient’s left-sided hemiparesis. On the following day, a repeat angiogram demonstrated no recurrence of vasospasm. The patient had complete return on neurologic function by post bleed day 18 continuing to her four-week follow-up appointment. This case demonstrates the feasibility of the Comaneci device as an effective tool in the treatment of vasospasm following subarachnoid hemorrhage.

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Risk factors for ischemic lesions following aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2005.102.2.0194 ◽

2005 ◽

Vol 102 (2) ◽

pp. 194-201 ◽

Cited By ~ 38

Author(s):

Seppo Juvela ◽

Jari Siironen ◽

Joona Varis ◽

Kristiina Poussa ◽

Matti Porras

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Artery Occlusion ◽

Ct Scans ◽

Content Type ◽

Fine Print

Object. The aim of this study was to test whether enoxaparin treatment (40 mg subcutaneously once daily) reduces the risk of cerebral infarction after subarachnoid hemorrhage (SAH) and to investigate predictive risk factors for permanent ischemic lesions visible on follow-up computerized tomography (CT) scans obtained 3 months after SAH. Methods. After undergoing surgery for a ruptured aneurysm, 170 patients were randomized in a prospective, double-blind, placebo-controlled trial to test the effect of enoxaparin on the occurrence of ischemic lesions, which were demonstrated on follow-up CT scans available for 156 patients. The presence of lesions correlated highly with an impaired outcome, as assessed using both the Glasgow Outcome and modified Rankin Scales (p < 0.01). Lesions occurred in 101 (65%) of the 156 patients. In half of the patients (51 patients) no lesion was visible on the CT scan obtained on the 1st postoperative day in 51 patients. On univariate analysis, the presence of lesions at 3 months post-SAH was not associated with enoxaparin treatment but did correlate with several clinical, radiological, and prehemorrhage variables. Significant independent risk factors for lesions consisted of an impaired initial clinical condition (odds ratio [OR] 2.63, 95% confidence interval [CI] 1.03–6.73), amount of subarachnoid blood (OR 6.51, 95% CI 2.27–18.65), nocturnal occurrence of SAH (that is, between 12:01 a.m. and 8:00 a.m.; OR 4.32, 95% CI 1.28–14.52), fixed symptoms of delayed ischemia (OR 5.21, 95% CI 1.02–26.49), duration of temporary artery occlusion during surgery (OR 1.66 per minute, 95% CI 1.20–2.31), and body mass index (OR 1.13/kg/m2, 95% CI 1.01–1.28). Conclusions The presence of ischemic lesions can be predicted by the severity of bleeding, delayed cerebral ischemia, excess weight, duration of temporary artery occlusion, and occurrence of nocturnal aneurysm rupture.

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Is Admission Lipoprotein-Associated Phospholipase A2 a Novel Predictor of Vasospasm and Outcome in Patients With Aneurysmal Subarachnoid Hemorrhage?

Neurosurgery ◽

10.1093/neuros/nyz041 ◽

2019 ◽

Vol 86 (1) ◽

pp. 122-131 ◽

Cited By ~ 2

Author(s):

Chen-Yu Ding ◽

Han-Pei Cai ◽

Hong-Liang Ge ◽

Liang-Hong Yu ◽

Yuang-Xiang Lin ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Clinical Outcome ◽

Phospholipase A2 ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Unfavorable Outcome ◽

World Federation ◽

Predictive Values ◽

Poor Grade ◽

Fisher Grade

Abstract BACKGROUND The relationships between lipoprotein-associated phospholipase A2 (Lp-PLA2) level, vasospasm, and clinical outcome of patients with aneurysmal subarachnoid hemorrhage (aSAH) are still unclear. OBJECTIVE To identify the associations between admission Lp-PLA2 and vasospasm following subarachnoid hemorrhage and the clinical outcome of aSAH. METHODS A total of 103 aSAH patients who had Lp-PLA2 level obtained within 24 h postbleeding were included. The relationships between Lp-PLA2 level, vasospasm, and clinical outcome were analyzed. RESULTS Vasospasm was observed in 52 patients (50.49%). Patients with vasospasm had significantly higher Lp-PLA2 level than those without (P < .001). Both modified Fisher grade (P = .014) and Lp-PLA2 level (P < .001) were significant predictors associated with vasospasm. The Z test revealed that power of Lp-PLA2 was significantly higher than that of modified Fisher grade in predicting vasospasm (Z = 2.499, P = .012). At 6-mo follow-up, 44 patients (42.72%) had unfavorable outcome and 36 patients (34.95%) died. The World Federation of Neurosurgical Societies (WFNS) grade and Lp-PLA2 level were both significant predictors associated with 6-mo unfavorable outcome and mortality (all P < .001). The predictive values of Lp-PLA2 for unfavorable outcome and mortality at 6-mo tended to be lower than those of the WFNS grade, but the differences were not statistically significant (P = .366 and 0.115, respectively). Poor-grade patients having Lp-PLA2 > 200 μg/L had significantly worse 6-mo survival rate than poor-grade patients having Lp-PLA2 ≤ 200 μg/L (P = .001). CONCLUSION The Lp-PLA2 might be useful as a novel predictor in aSAH patients. A total of 30 poor-grade patients; those with elevated Lp-PLA2 level have higher risk of 6-mo mortality compared to those without.

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“Silent” cerebral infarction due to vasospasm after SAH

Stroke ◽

10.1161/str.32.suppl_1.356-d ◽

2001 ◽

Vol 32 (suppl_1) ◽

pp. 356-356

Author(s):

Jan Claassen ◽

Stephan A Mayer ◽

Kurt T Kreiter ◽

Joseph E Bates ◽

Noeleen Ostapkovich ◽

...

Keyword(s):

Clinical Symptoms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Ct Scans ◽

Focal Neurological Deficit ◽

Poor Grade ◽

Symptomatic Vasospasm ◽

Asymptomatic Patients ◽

Continuous Eeg

P97 Objective. To determine frequency, impact on outcome, and determinants of clinically silent infarcts after aneurysmal subarachnoid hemorrhage (SAH) due to vasospasm. Methods. We prospectively studied a cohort of 326 patients with acute SAH. Delayed cerebral ischemia (DCI) was defined as (i) a new focal neurological deficit or decrease in level of consciousness otherwise unexplained, or (ii) a new infarct revealed by follow-up CT scans (within day 2–14 post hemorrhage) without other explanation. Angiography confirmed vasospasm in all patients. Results. DCI occurred in 18% (59/326) of patients. Of the 59 patients with DCI, 14 (24%) patients had an infarct on CT attributed to vasospasm without clinical deterioration, 25 had clinical symptoms and an infarct on CT, and 20 had clinical symptoms only. Compared to patients with symptomatic vasospasm, patients with “silent” infarcts more often had a Hunt-Hess score of 4–5 (64% vs. 27%, p=0.023), and blood in the 4th ventricle was found more often on the admission CT scan (86% vs. 45%, p=0.012). Variables that did not differ between symptomatic and asymptomatic patients included cisternal blood scores, hydrocephalus (bicaudate index), or edema on admission CT scans; aneurysm location; location of vasospastic infarcts; mean APACHE-2 scores; and mean TCD values. DCI patients without clinical symptoms had higher mortality at 3 months when compared with patients with clinical symptoms (60% vs. 14%, p=0.006). Conclusions. Clinically “silent” infarction occurs in approximately 25% of SAH patients with DCI, and is particularly common in poor grade patients with IVH. Because ischemia and infarction may go undetected in poor grade patients, prophylactic triple-H therapy, routine follow-up angiography with prophylactic angioplasty, and new monitoring techniques (e.g. continuous EEG) may lead to improved outcomes in these patients.

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