Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid hemorrhage: influence on clinical course and cerebral perfusion

Abstract

Background and purpose: The efficacy of intra-arterial administration of nimodipine (IAN) in patients with severe vasospasm after aneurysmal subarachnoid hemorrhage (SAH) remains unproved. The goal of the present study was to investigate the clinical effect and cerebral perfusion after IAN in patients with severe vasospasm refractory to hemodynamic treatment.

Materials and methods: Twenty-six of 214 patients with aneurysmal SAH were included in the prospective study, approved by the local ethics committee. All patients met the criteria of medically refractory cerebral vasospasm. Effectiveness was monitored angiographically by digital subtraction angiography and by transcranial Doppler (TCD), perfusion CT (PCT), and neurologic examination during treatment course and follow-up.

Results: No angiographic effect was observed in 8 patients. The pooled PCT values revealed a reduction of time to peak (P = .03) and mean transit time (P = .17) 1 day after intervention. This effect did not persist during the following days. The pooled TCD analysis demonstrated a transient increase in flow 1 day after intervention (P = .03). No trend was evident during the next 7 days after intervention. Additional infarction was experienced by 61.1% of patients.

Conclusions: IAN in a selective patient group resulted in a positive response with reduction of angiographic vasospasm and increase in cerebral perfusion as detected by PCT after 24 hours. Therefore, IAN appears more effective than intra-arterial papaverine. Nevertheless the efficacy of IAN is temporary. Therefore, the search for more effective treatment strategies to reduce critical vasospasm and to improve cerebral perfusion must be continued.

Fig 1.

The box-plot profiles of blood-flow velocity measured with TCD, from day 0 (preintervention) to the 7 days postintervention. The plus represents the sample mean value. The asterisk indicates P < .05 for the change from baseline.

Fig 2.

The box-plot profiles of perfusion parameters measured with perfusion CT: MTT (A), Tmax (B), cerebral blood flow (C), and cerebral blood volume (D), by time 0 (preintervention), 1 (first day after intervention), 2 (2–5 days postintervention), to 3 (5–9 days postintervention). The plus signs are the sample mean values. The asterisk indicates P < .05 for the change from baseline.

Fig 3.

Correlation between the first day change of flow velocity measured with TCD and the first day change of perfusion parameters measured with perfusion CT: MTT (A), Tmax (B), cerebral blood flow (C), and cerebral blood volume (D). Data are presented with correlation coefficients (r) and univariate linear regression with 95% confidence intervals.

Fig 4.

Illustrative case 12. A, Baseline angiogram on day 6 documents severe vasospasm in the left M1 and M2 segments (arrows). B, DSA obtained 10 minutes after the injection of 1.6-mg nimodipine reveals reduction of the vasospasm (arrows). C, PCT approximately 24 hours after IAN demonstrates a reduction of MTT and Tmax. D, No ischemic lesions are documented on the CT scan obtained at the time of discharge.