E-025 continuous intra arterial dilatation with combination of nimodipine and milrinone in severe and refractory vasospasm

Abstract

Purpose Cerebral Vasospasm (CVS) is a potentially devastating complication after aneurysmal subarachnoid hemorrhage. Although chemical angioplasty is effective, the effects are short lasting and multiple sessions of intra-arterial dilatation may be required. Intra-arterial infusions of nimodipine and milrinone have been used in isolation in nonrandomized studies to treat CVS. Balloon angioplasty is of limited value in patients with diffuse vasospasm involving distal vessels. We present our series of cases with refractory vasospasm treated by continuous intra-arterial infusion (CII) of both nimodipine and milrinone. Material and methods Eight patients [median age: 42.5 years, Male 4 (50%, n = 8)] with severe CVS and clinical deterioration despite maximum medical therapy underwent CII within 2 h of onset of clinical symptoms. All patients had early deterioration after intermittent intra-arterial vasodilatation. Procedure was performed under local anesthesia. After anticoagulation, microcatheter was positioned in the distal cervical internal carotid or vertebral artery through a diagnostic catheter. An infusion of nimodipine (3 mg) followed by milrinone (8 mg) was administered over 90 min. The diagnostic catheter was then withdrawn into descending aorta while maintaining the position of the microcatheter. Following this, a continuous infusion of nimodipine and milrinone was delivered intra-arterially at the rate of 2 mg/hr and 1mg/hr respectively for 72–168 h. During the period, heparinised saline was infused through both the catheters. In addition, systemic heparin was given to prevent thrombo-embolism. Duration of CII was determined by neurological status and transcranial Doppler. Results In six patients (75%, n = 8), neurological deficits improved and transcranial Doppler confirmed a reduction in mean blood flow velocity within 4 h. Neurological outcome was good (mRS score, 0–2) in five patients (62.5%, n = 8), whereas one patient had a moderate clinical outcome (mRS score, 3–4) and two patients had a poor outcome (mRS, 5) because of the SAH. Early institution of therapy correlated with better outcomes. A small thrombus around the microcatheter tip that resolved with continued heparin therapy was observed in one patient. Conclusion The effects of milrinone and nimodipine are probably synergistic due to their action on different receptors. Preliminary data show that CII with both nimodipine and milrinone is an effective and safe option for patients with severe and refractory CVS. Disclosures V. Gupta: None. G. Goel: None. R. Parthasarathy: None. A. Gupta: None. S. Anand: None. H. Sapra: None. A. Jha: None.