gms | German Medical Science

Objective: The treatment of secondary cerebral vasospasm (CVS) still poses a challenge in the treatment of patients with aneurysmal subarachnoid hemorrhage (SAH). Lately continuous intra-arterial infusion of calcium channel blockers has been used in severe symptomatic CVS. Milrinone, a phosphodiesterase inhibitor, which combines vasodilating and inotropic properties may become an alternative. We report of our first experiences with intra-arterial infusion of Milrinone in the treatment of severe CVS secondary to SAH.

Method: Ten patients with severe symptomatic CVS have been treated. All patients were monitored by transcranial Doppler sonography (TCD) and serial clinical evaluation of neurologic status. In intubated and sedated patients brain tissue oxygenation (p_tiO₂) was monitored. If symptomatic vasospasm became apparent (pathologic TCD velocity, pathologic p_tiO₂ value, new neurologic deficits), conservative treatment was initiated. If symptoms did not improve CT-angiography (CTA) was performed. In case of suspected vasospasm by CTA digital subtraction-angiography (DSA) was conducted for confirmation and possible intervention. In case of confirmed vasopasm Milrinone (8mg) was administered intra-arterially in the involved cerebral territories as a single infusion over 30 minutes. Post-interventionally neurological status, TCD, vessel size by DSA, and clinical outcome at discharge using the modified ranking scale (mRS) was analyzed.

Results: Immediate visible increase in arterial diameter by DSA could be stated in 9 of 10 patients. Seven patients experienced neurologic improvement following Milrinone infusion. In five patients a decrease in blood flow velocity measured by TCD was documented. Two intubated and sedated patients showed a relevant increase in p_tiO₂. Recurrence of vasospasm was seen in 3 patients. In 2 of them re-dilatation could be achieved by another intra-arterial infusion of Milrinone. The remaining patient was treated with Nimodipin infusion via microcatheters. One patient died after initial successful treatment of CVS due to major blood loss from the punctuation site and consecutive cerebral hypoperfusion.

Conclusions: Intra-arterial single Milrinone application appears to be safe with an immediate and persisting effect on CVS in 7 of 10 patients. Therefore, it could be an alternative to the continuous intra-arterial infusion of Nimodipin via microcatheters or Papavarin.