Vasospasm, DCI and the screening problem

Recorded in August 2025 with an AI co-host, this episode is a tour of the part of SAH care that still is not solved. It starts with the distinction that everything else depends on: radiological vasospasm is something you see on a scan, delayed cerebral ischaemia is something you diagnose at the bedside, and the two overlap far less neatly than the history of the field assumed.

From there it works through the practical arguments. Systolic or MAP targets. The HIMALAIA signal on induced hypertension. TCD versus CTA versus CT perfusion as a screen, and whether a GCS 15 patient with expert nursing needs screening at all. Milrinone and the vasopressor problem it creates. And whether multimodal monitoring is ever going to be more than a trigger for the next scan.

Worth listening for

• Why the clazosentan trials mattered even though they failed: they forced the field to look past large-vessel spasm.

• The little old lady on 20 of noradrenaline to reach a systolic of 120, and whether that is in her interest.

• Every DSA has a cost: the DWI lesions nobody looks for, and what cumulative angiography might do to a brain.

• The case for CT perfusion: narrowing without a perfusion deficit may not need a trip to the angio suite.

Where this shows up in the program

Julian Maingard presents the evidence and real-world practice of CT perfusion for DCI on Thursday morning. The same day has a breakout on haemodynamic escalation strategies in ICU, Martin Banez on stentplasty for refractory vasospasm, and a run of rapid-fire abstracts on multimodal monitoring, including a prospective study monitoring DCI treatment in unconscious patients and bedside 3D contrast-enhanced ultrasound for spasm.

Thursday afternoon ends with Loch Macdonald leading a panel on the most promising treatments on the horizon for DCI, and on Friday Michael Veldeman updates on endovascular treatment of symptomatic vasospasm and DCI. The tension in this episode, between treating what you can see and treating what is actually causing ischaemia, is the meeting’s central argument.

One correction to the episode: the meeting is in November 2026, not October. The AI did not get that one wrong; we did.

Listen above, or go to the full episode and transcript on NeuroResus.

ISAH 2026 runs 17–20 November at the Sheraton Grand Hyde Park, Sydney. See the program or register here.