Abstract
Introduction: Vasospasm causing delayed cerebral ischemia (DCI) remains a leading cause of morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH). Our previously reported series detailed the safety and efficacy of cardiac doses of milrinone in DCI. Since 2007, we have been treating refractory delayed cerebral ischemia (RDCI) with very large doses of IV milrinone. We report the safety and clinical effect of high-dose milrinone in aSAH with RDCI. Methods: Retrospective single center analysis of all patients treated between October 2014 and July 2015 for vasospasm refractory to the MNH protocol (RDCI). RDCI patients received a bolus and perfusion that were increased incrementally until resolution of signs. If 2 boluses and 2 increases in perfusion were unsuccessful, patients underwent angiogram for intra-arterial (IA) milrinone and possible angioplasty. Results: 40 patients were admitted for acute aSAH. Vasospasm was diagnosed clinically in 26 (65%). Initial milrinone therapy included a loading dose of 6 mg and an infusion of 0.75 mcg/kg/min. Of these patients, 18 had RDCI and received boluses of up to 8mg IV with perfusions of up to 2.75 mcg/kg/min. The maximum cumulative daily dose of milrinone was 230mg. There were no adverse cardiovascular events due to the drug. Neurologic improvement was seen in 8/18 with large IV bolus and perfusion of milrinone. Ten patients required angiography; all received IA milrinone, and angioplasty was performed in 3. Modified rankin scale (mRS) ≤ 2 on discharge was achieved in 6 of the 8 patients who improved with high-dose IV milrinone alone, 2 of 3 patients undergoing angioplasty and 4 of the 7 patients receiving IA milrinone without angioplasty. Conclusion: High doses of IV milrinone were effective in a large proportion of our patients with vasospasm and RDCI after aSAH, and it was extremely safe. This treatment could be considered prior to angioplasty.
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