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. 2014:2014:970741.
doi: 10.1155/2014/970741. Epub 2014 Jan 16.

Continuous selective intra-arterial application of nimodipine in refractory cerebral vasospasm due to aneurysmal subarachnoid hemorrhage

Stephanie Ott  1 , Sheila Jedlicka  1 , Stefan Wolf  2 , Mozes Peter  3 , Christine Pudenz  1 , Patrick Merker  4 , Ludwig Schürer  1 , Christianto Benjamin Lumenta  1
Affiliations

Continuous selective intra-arterial application of nimodipine in refractory cerebral vasospasm due to aneurysmal subarachnoid hemorrhage

Stephanie Ott et al. Biomed Res Int. 2014.

Abstract

Background: Cerebral vasospasm is one of the leading courses for disability in aneurysmal subarachnoid hemorrhage. Effective treatment of vasospasm is therefore one of the main priorities for these patients. We report about a case series of continuous intra-arterial infusion of the calcium channel antagonist nimodipine for 1-5 days on the intensive care unit.

Methods: In thirty patients with aneurysmal subarachnoid hemorrhage and refractory vasospasm continuous infusion of nimodipine was started on the neurosurgical intensive care unit. The effect of nimodipine on brain perfusion, cerebral blood flow, brain tissue oxygenation, and blood flow velocity in cerebral arteries was monitored.

Results: Based on Hunt & Hess grades on admission, 83% survived in a good clinical condition and 23% recovered without an apparent neurological deficit. Persistent ischemic areas were seen in 100% of patients with GOS 1-3 and in 69% of GOS 4-5 patients. Regional cerebral blood flow and computed tomography perfusion scanning showed adequate correlation with nimodipine application and angiographic vasospasm. Transcranial Doppler turned out to be unreliable with interexaminer variance and failure of detecting vasospasm or missing the improvement.

Conclusion: Local continuous intra-arterial nimodipine treatment for refractory cerebral vasospasm after aSAH can be recommended as a low-risk treatment in addition to established endovascular therapies.

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Figures

Figure 1
Figure 1
DSA before and after nimodipine application at the angiography unit. Digital subtraction angiography of the left internal carotid artery before (a) and after (b) nimodipine application in the angiography unit. It shows slight improvement of vasospasm after nimodipine infusion. Intra-arterial infusion of the calcium channel antagonist was continued on the neurosurgical intensive care unit.
Figure 2
Figure 2
Perfusion CT correlating with DSA. CT perfusion with MTT (sec) (a), TTP (sec) (b), CBF (mL/100 g/min) (c), and CBV (mL/100 g) (d) showing circumscribed perfusion deficit on the territory of the left MCA. No evidence of infarction as shown on native CT scan (f). Digital subtraction angiography (e, g) of the left ICA from the same patient on the same day showing vasospasm of the left ICA above the ophthalmic artery of the median and anterior cerebral artery.
Figure 3
Figure 3
Correlation of H&H grade and patient outcome. Spearman rank test shows inverted correlation of Hunt & Hess grade on admission and outcome (GOS) on discharge.
Figure 4
Figure 4
Correlation of onset of selective continuous intra-arterial nimodipine infusion and patient outcome. Spearman rank test shows that inverted correlation of the day nimodipine infusion was started with the outcome (GOS) on discharge.
Figure 5
Figure 5
Linear correlation test shows extremely high significance of ptiO2 and rCBF values during (day 1) selective continuous intra-arterial nimodipine infusion.
See this image and copyright information in PMC

References

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