Endovascular treatment of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage – an international survey

Abstract Background Delayed cerebral ischemia (DCI) is a major cause of morbidity after aneurysmal subarachnoid hemorrhage (SAH). Endovascular treatment (ET) has emerged as a rescue strategy, but its optimal timing, indication, and modality remain unclear. This study assessed international ET practices, focusing on treatment variability and clinical decision-making. Methods A 25-question survey was developed with input from specialists in interventional neuroradiology, neurosurgery, neurology, and neurocritical care. It was disseminated via professional societies to physicians involved in bedside decisions. Respondents reviewed clinical scenarios representing common DCI presentations, including proximal/distal vasospasm and conscious/unconscious patients. Descriptive analysis was performed. Results 179 respondents from 38 countries participated; 76.5% reported ET availability at their institution. The most common strategy was single or repeated intra-arterial spasmolysis (76.5%), followed by continuous intra-arterial vasodilator infusion (23.0%). In unconscious patients, 50% applied spasmolysis as first-line treatment. For refractory proximal vasospasm, a stepwise approach was preferred, starting with intra-arterial pharmacologic spasmolysis, then angioplasty. While angioplasty was widely used, 66.5% considered it riskier than spasmolysis. Conclusion This survey highlights marked variability in ET practices for DCI. Intra-arterial spasmolysis is the predominant strategy, with alternative approaches like continuous infusion and angioplasty also in use. These findings underscore the need for randomized trials to define optimal ET strategies and inform evidence-based protocols for DCI following SAH.