Novel application of the NeVa VS device in the management of severe vasospasm after meningitis

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Korean J Cerebrovasc Surg. 2026;.jcen.2026.E2025.11.001

Publication date (electronic) : 2026 June 16

doi : https://doi.org/10.7461/jcen.2026.E2025.11.001

Stephen Jaffee¹, Romil Singh¹, Praneetha Bheemarasetty², Nihas Mateti^,1, Seung Jeong¹, Hassan Abdullah Shakeel¹, Mokshal Porwal¹, Andrew Ku¹

¹Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA

²Department of Neurosurgery, Drexel University College of Medicine, Philadelphia, PA, USA

Correspondence to Nihas Mateti Department of Neurosurgery, Allegheny General Hospital, 320 E North Ave, Pittsburgh, PA 15212, USA Tel +1-412-359-8850 Fax +1-412-259-8878 E-mail nihas.mateti@ahn.org

Received 2025 October 23; Revised 2026 March 3; Accepted 2026 May 17.

Abstract

INTRODUCTION

Cerebral vasospasm (CV) is a reversible, prolonged narrowing of intracranial arteries often seen after aneurysmal subarachnoid hemorrhage (aSAH) and insufficiently managed, leading to delayed cerebral ischemia [2,5,9]. Untreated, CV can progress to delayed cerebral ischemia in 20–30% of subarachnoid hemorrhage cases and worsens morbidity and mortality [2,5,9]. Endovascular treatment for CV after aSAH includes intra-arterial administration of vasodilatory medications and balloon angioplasty to improve cerebral perfusion. Intra-arterial drug infusion often requires repeated interventions and mechanical balloon angioplasty is linked to vessel rupture and thromboembolic events. Temporary balloon occlusion also presents a risk of worsening cerebral ischemia. A retrievable stent device (NeVa VS; Vesalio, Nashville, Tennessee, USA) has been demonstrated effective and safe for treating CV after aSAH. Less commonly, CV occurs with central nervous system infections, but the role of endovascular treatment in such cases has not been well defined. We describe a patient with severe infectious vasospasm, subdural empyema, and bacterial meningitis who successfully underwent endovascular angioplasty using the retrievable stent device.

CASE DESCRIPTION

A male in his 20s with a history of asthma presented to an outside hospital with two weeks of sore throat, nasal congestion, and rhinorrhea. He was diagnosed with tonsillitis; throat cultures grew Group C Streptococcus, and he was prescribed 10 days of amoxicillin. Two days after completing the antibiotics, he developed bilateral facial pain, sustained a fall with a strike to the head, and developed forehead edema and greenish colored discharge from the right nostril. He presented to the emergency department, and a computed tomography (CT) scan without contrast indicated periorbital cellulitis with right frontal cerebral edema with concern for cerebritis in the setting of the patient’s sinus infection.

Magnetic resonance imaging (MRI) with and without contrast demonstrated pan-sinus opacification and right-sided pneumocephalus with frontal lobe cerebritis. Lumbar puncture values included a glucose of 88 mg/dL (reference 40–70 mg/dL), lactate of 3.4 mmol/L (reference 1.1–2.4 mmol/L), and protein of 50 mg/dL (reference 15–45 mg/dL), and cultures showed no growth. The patient subsequently developed left-sided flaccid hemiparesis, and an electroencephalography (EEG) ruled out non-convulsive status epilepticus. A second MRI demonstrated worsened cerebritis and a new 5 mm right-sided subdural empyema (Fig. 1). MR/CT perfusion and CT Angiogram demonstrated mild hypoperfusion in the right anterior cerebral artery (ACA) and middle cerebral artery (MCA) territories with diffuse vasospasm (Fig. 2). The patient subsequently developed left-sided flaccid hemiparesis with Medical Research Council (MRC) grade 1/5 strength in the left upper and lower extremities.

Fig. 1.

Magnetic resonance imaging (MRI) brain with contrast (subdural empyema): Axial MRI brain (FLAIR) with contrast demonstrating a 5 mm right-sided subdural empyema with associated right frontal lobe cerebritis.

Fig. 2.

Magnetic resonance imaging / computed tomography (MR/CT) perfusion maps demonstrate mild hypoperfusion in the right anterior cerebral artery and middle cerebral artery territories (white arrow in A), with prolonged mean transit time (MTT) (white arrow in B). (C) CT angiography (bottom) demonstrates diffuse vasospasm (marked arrows) of the right-sided intracranial vasculature prior to endovascular intervention.

On hospital day two, the patient developed symptoms of distributive shock, despite negative blood cultures, and required pressor support to sustain mean arterial pressures greater than 65 mmHg. A cerebral angiogram was ordered to treat the vasospasm because hemodynamic instability precluded an empyema evacuation, as hypoperfusion could reduce blood flow to tenuous parenchyma. The angiogram confirmed moderate to severe vasospasm of the right supraclinoid internal carotid artery (ICA) and M1 segment, as well as the distal MCA and ACA cortical vessels (Fig. 3). 40 mg of intra-arterial verapamil was administered in the right ICA. The patient initially stabilized but subsequently deteriorated. A repeat angiogram three days later revealed severe vasospasm of the right M1 segment with moderate to severe vasospasm of the right supraclinoid ICA.

Fig. 3.

Digital subtraction angiography of the right internal carotid artery (ICA) pre-intervention. Anteroposterior (AP) (A) and lateral (B) views centered over the intracranial circulation demonstrate severe vasospasm of the right M1 segment and moderate vasospasm of the right supraclinoid ICA. Magnified AP view centered over the right M1 segment (C) further demonstrates severe vasospasm of the right M1 segment with a residual lumen of 0.6 mm.

An angioplasty was conducted using the NeVa VS device on the entire right MCA M1 segment and the supraclinoid right ICA (Fig. 4). The NeVa VS retrievable stent was deployed 5 times across the right MCA M1 segment and the supraclinoid ICA, with each deployment maintained for approximately 5 minutes. An intravenous heparin bolus of 5,000 units was administered periprocedurally to maintain an activated clotting time greater than 250 seconds. No antiplatelet agents were administered, given the infectious etiology and concurrent empyema. Verapamil was then infused to treat the distal right MCA M2 and M3 vasospasm and distal ACA vasospasm. A new 1.5×2.4 mm distal ACA mycotic aneurysm was identified and successfully embolized in the same session. No periprocedural complications were observed, including no vessel rupture, dissection, or thromboembolic events.

Fig. 4.

Single-shot fluoroscopy with anteroposterior and lateral views centered over the right intracranial circulation. (A & B) Deployment of the retrievable stent device within the M1 segment of the right middle cerebral artery. (C & D) Deployment of the device within the supraclinoid internal carotid artery.

Subsequent angiogram demonstrated improved vessel caliber and flow (Fig. 5), and the neurological assessment demonstrated improvement in left hemiparesis with MRC score of 3/5 in left upper extremity and 2/5 in left lower extremity. Several days later, the patient was more hemodynamically stable and was taken for a subdural empyema evacuation. The patient’s neurological status continued to improve, and he was discharged to inpatient rehabilitation. Post-hospital discharge, the patient was seen in clinic after an interval of 4 months, and the patient demonstrated motor strength of 5/5 in both upper and lower extremities.

Fig. 5.

Digital subtraction angiography of the right internal carotid artery (ICA) post-intervention. Anteroposterior (A) and lateral (B) views centered over the intracranial circulation demonstrate significantly improved vessel caliber of the right M1 and supraclinoid internal carotid artery segments with improved flow.

DISCUSSION

Most cases of infection-related vasospasm are successfully treated with antibiotics and supportive care, but our patient’s vasospasm was so severe in the supraclinoid right ICA and entire right MCA M1 segment that angioplasty was critical to promote hemodynamic stability and mitigate the risk of subdural empyema evacuation. The decision to pursue endovascular angioplasty in the setting of active bacterial infection required careful risk-benefit analysis. Intra-arterial verapamil was initially administered but provided only transient improvement, with repeat angiography demonstrating worsening vasospasm of the right M1 segment. Repeated vasodilator infusion was deemed insufficient given the severity and progression of the vasospasm and the patient’s ongoing hemodynamic instability. Surgical empyema evacuation, while necessary, was deferred initially because the combination of distributive shock and compromised cerebral perfusion created an unacceptably high risk of intraoperative cerebral ischemia. Angioplasty was therefore pursued to stabilize cerebral perfusion and create a safer hemodynamic window for subsequent surgery. While mechanical angioplasty in an inflamed vessel carries theoretical risks including vessel wall fragility and increased thrombogenicity, the use of a retrievable stent, which avoids prolonged vessel occlusion and allows flow preservation, was felt to mitigate these concerns.

The severe vasospasm of the proximal right MCA M2 and the distal right MCA M1 required Dotter or micro-balloon angioplasty (with the NeVa delivery catheter) to obtain access. Cerebral blood flow was maintained in the supraclinoid right ICA and right MCA during the angioplasty for over 2–3 minutes due to the long segment of occlusion. This would not have been possible if a micro-balloon had been utilized. Conventional balloon angioplasty requires temporary vessel occlusion during inflation, which, in the setting of prolonged, long-segment vasospasm, risks worsening ischemia to already vulnerable parenchyma. The retrievable stent device, by contrast, maintains antegrade blood flow throughout deployment, allowing treatment of extended vessel segments, in our case, the entire right MCA M1 and supraclinoid ICA, without interruption of perfusion. This property was particularly important given our patient’s tenuous hemodynamic state and existing hypoperfusion.

Intra-arterial vasodilators such as verapamil act primarily by relaxing smooth muscle but have a short duration of action and often require repeated administration. In contrast, retrievable stent angioplasty directly dilates the narrowed vessel segment, producing a more durable restoration of luminal caliber. Prior studies in aSAH-related vasospasm have demonstrated that balloon and stent-assisted angioplasty achieve longer-lasting improvement in vessel diameter compared to pharmacological therapy alone, with effects persisting beyond the acute procedural period.6) The retrievable stent also maintains antegrade cerebral blood flow during deployment, a critical advantage when treating long-segment vasospasm, which is not possible with conventional balloon angioplasty because of temporary vessel occlusion.

An important distinction must be made between infectious cerebral vasospasm and infectious vasculitis, as these entities differ in pathophysiology, angiographic appearance, and implications for mechanical intervention. Vasculitis typically involves transmural inflammatory infiltration of the vessel wall, producing irregular, segmental stenoses that may be irreversible and carry a higher risk of vessel injury during mechanical manipulation. In contrast, vasospasm is characterized by smooth, diffuse, reversible arterial narrowing driven by transient smooth muscle contraction in response to inflammatory mediators [3,4,7]. In our patient, the angiographic appearance demonstrated smooth, symmetric narrowing of the supraclinoid ICA and M1 segment with subsequent improvement following angioplasty, consistent with a vasospastic rather than vasculitic process. We acknowledge, however, that vessel wall MRI was not performed, which would have provided additional evidence regarding the presence or absence of mural enhancement and wall thickening characteristic of vasculitis. This limitation should be considered when interpreting our findings.

There is limited literature describing the connection between infectious vasospasm and CV. Taqui et al. reported two patients with para-infectious CV who significantly improved with intra-arterial vasodilator agents [11]. In contrast, Norman et al. report a case of P1 CV secondary to meningitis managed initially with steroids and verapamil but eventually taken for an angiogram with intra-arterial milrinone and balloon angioplasty [8]. Prior to our case, there has been one report of permanent intracranial stenting for refractory post-infectious cerebral vasculitis secondary to pneumococcal meningitis, in contrast to our use of a retrievable stent [1]. Intra-arterial verapamil was insufficient for the severe vasospasm in our patient; thus, angioplasty should be considered in refractory cases. While the NeVa stent device was mainly approved for use in CV associated with aSAH, our case demonstrates its use for infectious vasospasm [10].

CONCLUSIONS

This case demonstrates that endovascular angioplasty with a retrievable stent device can be a safe and effective rescue option for severe, refractory infectious cerebral vasospasm refractory to medical therapy. When intra-arterial vasodilators are insufficient and surgical intervention cannot be safely performed due to hemodynamic instability, retrievable stent angioplasty may restore cerebral perfusion and serve as a bridge to definitive surgical management. Given the limited evidence base and the inherent risks of mechanical intervention in the setting of active infection, this approach should be reserved for highly selected cases in which alternative options have been exhausted. Further case series and prospective data are needed to better define patient selection criteria, procedural safety, and long-term outcomes.

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