Case Report Treatment of cerebral vasospasm secondary to subarachnoid hemorrhage utilizing the Comaneci device Interventional Neuroradiology 1–4 ! The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1591019920945554 journals.sagepub.com/home/ine Clint A Badger1 , Brian T Jankowitz1 and Hamza A Shaikh1,2 Abstract 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. Keywords Subarachnoid, hemorrhage, stroke, angioplasty, stent Received 9 May 2020; accepted 29 June 2020 Background Vasospasm remains an important cause of delayed neurological deterioration in patients with subarachnoid hemorrhage (SAH). Angiographic vasospasm occurs in 70% of patients; typically starting on post bleed days 3–4, peaking at days 7–10, and resolving by days 14–21.1 Symptomatic vasospasm, leading to delayed cerebral ischemia, can occur in up to 30% of patients.1–3 Current literature supports the prevention of vasospasm by prophylactic measures such as maintaining euvolemia and concurrent use of nimodipine. Augmentation of systolic and mean arterial blood pressures can also be utilized for vasospasm detected by transcranial doppler (TCD) studies or a screening cerebral angiogram. When neurological deficits are present, endovascular therapy with intraarterial (IA) vasodilators and angioplasty are imployed.2,4 Endovascular infusions carry a low risk but have transient benefits, most requiring repeat treatments. More aggressive treatment involves balloon angioplasty. This modality can prove to be highly effective, although it blocks anterograde blood flow in an already ischemic brain and carries a 1.1% risk of vessel perforation.2,5 At our institution, standard treatment for asymptomatic vasospasm detected on TCD studies or screening DSA involves maintenance of euvolemia, augmentation of systolic blood pressure above 140 mm Hg, and Q1 hour neurological checks. Patients with presumed symptomatic vasospasm undergo a cerebral angiogram to cement the diagnosis. If mild (0–25%) to moderate (25–50%) vasospasm is seen, IA verapamil and/or nicardipine is selectively infused. Severe (50–75%) to critical (75–100%) vasospasm is treated with balloon angioplasty followed before or after with IA medications. Recently, there have been reports utilizing stentretrievers to treat vasospasm.3,5–7 Given the advantages of continued anterograde flow and decreased risk of vessel perforation, they have shown encouraging results. However, they can only expand to a predetermined diameter and radial force.8,9 Here, we present a case of symptomatic vasospasm treated with the Comaneci 17 (Rapid Medical, Yokneam, 1 Department of Neurosurgery, Cooper University Hospital, Camden, NJ, USA 2 Department of Radiology, Cooper University Hospital, Camden, NJ, USA Corresponding author: Hamza A Shaikh, Departments of Neurosurgery and Radiology, Cooper University Hospital, Three Cooper Plaza, Suite 104, Camden, NJ 08103, USA. Email: Shaikh-Hamza@cooperhealth.edu 2 Israel), a device currently FDA approved for temporary coil embolization assistance in wide-necked aneurysms.10 Case presentation A female in her 40s with no medical history presented with the worst headache of her life. She stated the headache was of acute onset post coitus. She was neurologically intact on examination, presenting as a Hunt and Hess score 2. A non-contrast CT and CT angiography (CTA) of the head was completed demonstrating SAH with a fisher score of 3 without an identified aneurysm. Diagnostic angiogram was performed also without an identifiable aneurysm (Figure 1(a) and (b)). The patient was admitted to the intensive care unit (ICU) under SAH protocol and started on nimodipine 60 mg every 4 h. As is standard for angio-negative SAH in our institution, the patient underwent repeat angiogram on post-bleed day 7 which was negative for aneurysm and vasospasm. On post-bleed day 10, the patient developed progressive left-sided hemiparesis and facial droop with 0/5 strength in the left arm and leg. She was taken for CTA and CT perfusion (CTP) demonstrating vasospasm of the right internal carotid artery (ICA), middle cerebral artery (MCA), and anterior cerebral artery (ACA) with elevated mean transit time and spared cerebral blood flow, indicating an ischemic penumbra. As the patient had a severe neurological deficit with confirmed vasospasm on imaging, she was taken for an emergent angiogram with planned intervention. Treatment Right femoral access was obtained, and initial anterior and lateral projections of the angiogram demonstrated severe right-sided vasospasm Interventional Neuroradiology 0(0) (Figure 2(a) and (c)). Utilizing a Syncro2 standard microwire, a Headway 17 microcatheter was navigated through a NeuronMAX 088 guide catheter into the distal right ICA. The Headway 17 was then navigated over the microwire into the superior M2 segment and the Comaneci 17 was deployed. Under live fluoroscopy, the device was slowly opened with an injection of contrast after each incremental “click” until the vessel appeared its normal diameter. The Comaneci 17 was left at that diameter for approximately 30 s after which it was closed. Next it was navigated into the inferior M2 segment, M1 segment, and then ICA terminus where the same sequence was repeated. The Comaneci 17 required maximal deployment to a diameter of 3.0 mm in the M1 segment and ICA terminus. Lastly, it was navigated into the right A2 and A1 segments for angioplasty (Figure 3). Final angiogram post-Comaneci angioplasty demonstrated significant improvement of vasospasm in all treated vessels (Figure 2(b) and (d)). As vasospasm was still visible distal to where the Comaneci 17 could safely be deployed, 20 mg of IA verapamil was slowly injected over 20 min into the distal right ICA. Outcome and follow-up Post procedure, the patient had immediate improvement in her left-sided hemiparesis. She was monitored in the ICU where her systolic blood pressure was maintained above 160 mmHg. The following day, an MRI was performed showing a relatively low stroke volume within the right corona radiata (Figure 4(a)). An angiogram was also performed demonstrating continued effect of the treatment without recurrence of vasospasm within the treated vessels (Figure 4(b)). The patient was discharged from the hospital on post bleed day 18 where she had complete resolution of her symptoms with normal strength of the left arm and leg. On follow-up four weeks after discharge, the patient did not have any recurrence of symptoms. Figure 1. Right ICA anterior (a) and lateral (b) projections demonstrating normal caliper ICA terminus, ACA, and MCA vessels without an identifiable aneurysm. Badger et al. 3 Figure 2. Right ICA injection through a NeuronMAX 088 guide catheter. (a) Anterior projection showing severe vasospasm throughout the right ACA and MCA distributions. (b) Anterior projection post-Comaneci angioplasty with improvement in vasospasm of the M1, M2, ICA terminus, and A1 segments. (c) Lateral projection showing severe vasospasm of the A1 and A2. (d) Lateral projection post-Comaneci angioplasty demonstrating improvement in vasospasm, with persistent vasospasm of the left A2 segment. Figure 3. Right ICA injection demonstrating the expanded Comaneci 17 device within the ICA terminus and A1 segments. Discussion Endovascular treatment of vasospasm has historically consisted of IA infusions, which can be short lasting requiring multiple treatments, as well as balloon angioplasty.1,2,4 Balloons can exert high radial forces on vessel walls but can lead risk vessel injury if too much force is exerted. These balloons also impede forward flow of blood potentiating cerebral ischemia.3,5,8 The use of stent-retrievers has recently been described as a viable treatment alternative with good results. Given the flow rate of a vessel is directly related to its radius to the fourth power, even some improvement in radius can have a substantial effect.3,8 Recent studies utilizing stent-retrievers have shown an exertional force up to 23 kPa, enough to create a clinically significant increase in vessel radius while limiting their ability to cause injury.5 Additionally, they do not impede anterograde blood flow. One drawback is their fixed diameter, so if their final diameter is not the true size of the vessel an insufficient dilatation may occur, limiting treatment effects. The Comaneci device is a compliant radiopaque mesh composed of 12 nitinol wires mounted on a core wire with three versions currently available. The standard version has a diameter of 1.5 mm– 4.5 mm with a length ranging from 32 mm to 12 mm when fully deployed. The Comaneci Petit has a diameter of 1.5 mm–3.5 mm and a length of 24 mm to 21 mm. Both need to be delivered through a 0.02100 microcatheter and are typically used in the distal ICA and basilar arteries. For more distal vessels, the Comaneci 17 can be utilized. It is delivered through an 0.01700 microcatheter with diameters ranging from 0.5 to 3.0 mm and a length of 22 mm to 16 mm.10 Each device has 19 increments in its opening. Each increment increases the diameter of the device while also decreasing its length. The amount of diameter increase is variable on each patient’s vessel anatomy. When placed in more tortuous vessels, the device will have less increase in diameter per increment.9 Currently, the use of the Comaneci to treat vasospasm is off-label. However, when compared to stentretrievers, the Comaneci can provide a sequentially higher radial force at each incremental increase of the device’s diameter, providing the operator greater control over the applied radial force to the treated vessel. When deployed, the 6 mm Solitaire stentretriever is able to exert 0.02 N/mm of radial force onto a 1.5 mm vessel decreasing to 0.015 N/mm in a 3 mm vessel.8 The Comaneci 17 when fully expanded exerts a radial force between 0.05 and 0.06 N/mm in a 1 mm vessel to slightly less than 0.04 N/mm in a 3 mm 4 Interventional Neuroradiology 0(0) Figure 4. (a) MRI of the brain B1000 sequence demonstrating restricted diffusion within the right corona radiata. (b) Right ICA injection performed one day post angioplasty demonstrating resolution of vasospasm within M1, M2, ICA terminus, and proximal A1 segments. There is improved but persistent mild vasospasm of the distal A1 and A2 segments. vessel.8,9 The ability of the Comaneci to be sequentially expanded allows the operator to gradually increase its applied force while also monitoring dilatation in an attempt to prevent vessel injury. The additional and variable radial force when compared to stentretrievers and continued anterograde blood flow when compared to balloons may provide the Comaneci the ability to more effectively treat vasospasm with the potential for lower risk of vessel injury. Conclusion Cerebral vasospasm can be treated by many modalities, both medical and endovascular. Of the endovascular modalities, balloon angioplasty is highly effective but carries the risks of vessel perforation and worsening cerebral ischemia. Stent-retrievers provide continued perfusion but are limited by their predetermined diameter and low radial force. As seen with our case, the Comaneci may prove to be an effective alternative for angioplasty providing continued cerebral perfusion, adjustable diameter/radial force, and the potential for lower risk of vessel injury. As this is currently an off-label use, larger case series and trials need to be completed in order to further investigate its safety and efficacy in the treatment of cerebral vasospasm. Declaration of conflicting interests The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Brian Jankowitz reports that he is a paid consultant for Medtronic and Stryker. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. ORCID iD Clint A Badger https://orcid.org/0000-0002-6036-3116 References 1. Lawton MT and Vates GE. Subarachnoid hemorrhage. N Engl J Med 2017; 377: 257–266. 2. Findlay JM, Nisar J and Darsaut T. Cerebral vasospasm: a review. Can J Neurol Sci 2016; 43: 15–32. 3. Bhogal P, Loh Y, Brouwer P, et al. Treatment of cerebral vasospasm with self-expandable retrievable stents: proof of concept. J Neurointerv Surg 2017; 9: 52–59. 4. Boulouis G, Labeyrie MA, Raymond J, et al. Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and Meta-analysis. Eur Radiol 2017; 27: 3333–3342. 5. Su YS, Ali MS, Pukenas BA, et al. Novel treatment of cerebral vasospasm using solitaire stent retrieverassisted angioplasty: case series. World Neurosurg 2020; 135: e657–e663. 6. Kwon HJ, Lim JW, Koh HS, et al. Stent-retriever angioplasty for recurrent post-subarachnoid hemorrhagic vasospasm – a single center experience with long-term follow-up. Clin Neuroradiol 2019; 29: 751–761. 7. Bhogal P, Paraskevopoulos D and Makalanda HL. The use of a stent-retriever to cause mechanical dilatation of a vasospasm secondary to iatrogenic subarachnoid haemorrhage. Interv Neuroradiol 2017; 23: 330–335. 8. Bhogal P, Pederzani G, Grytsan A, et al. The unexplained success of stentplasty vasospasm treatment: insights using mechanistic mathematical modeling. Clin Neuroradiol 2019; 29: 763–774. 9. Radial force bench testing for Comaneci and Solitaire. Rapid Medical. Yokneam, Israel. Unpublished data. In. Rapid Medical Yokneam, Israel. 10. Sirakov S, Sirakov A, Hristov H, et al. Early experience with a temporary bridging device (comaneci) in the endovascular treatment of ruptured wide neck aneurysms. J Neurointerv Surg 2018; 10: 978–982.