gms | German Medical Science

Objective: Delayed cerebral ischemia (DCI) is one main reasons of unfavorable outcome following aneurysmal subarachnoid hemorrhage (SAH). Secondary macrovasospasm and disturbance of cerebrovascular autoregulation have been identified as associated risk factors. Interventional spasmolysis with application of papaverin or nimodepine was shown to be effective on vessel diameter, however with transient effects only. We evaluated the effects of continuous intraarterial nimodepine infusion (CIN) on macrovasospasm, autoregulation and outcome in selected patients with refractory severe vasospasm.

Method: 10 patients (8 female, 2 male, mean age 39y) were included with either refractory vasospasm and infarctions despite interventional spasmolysis (n=4) or primary severe vasospasm. Patients had continuous multimodal neuromonitoring (ABP, ICP, pbrO2), daily transcranial doppler (TCD) exams, and CT-angiography (CTA) if indicated. ICM+ software was used to calculate CPP and cerebrovascular autoregulation indices PRx and ORx. Prowler microcatheters were placed in (both) extracranial internal carotid arteries (ICA) and 0.4 mg nimodepine in 50 ml/h was infused each. Patients were heparinized (to PTT 60s).

Results: Mean duration of spasmolysis was 12.0 days (range 9-15). ICP remained stable, TCD flow velocity decreased, pbrO2 improved by 37%, vasospasm according to CTA was improved (n=5) or disappeared (n=5) at the end of treatment. Cerebrovascular autoregulation, however, was lost during treatment according to PRx and ORx. Two patients suffered additional small infarcts, however, outcome at discharge was GOS 4&5 in all 10 patients. In 2/10 patients minor complications (catheter dislocation, extracerebral bleed) were seen.

Conclusions: CIN treatment according to our protocol was save and seems effective in preventing DCI in selected patients with severe vasospasm and high risk profile for unfavorable outcome. Despite the fact, that nimodepine lead to loss of cerebrovascular autoregulation, which per se is known to be associated with DCI under standard treatment, the overall effect on macrovasospasm and tissue perfusion was beneficial. A possible contribution of heparinization cannot be excluded. A randomized prospective study with larger patient numbers is necessary to confirm the efficacy of CIN in the prevention of DCI.