gms | German Medical Science

Objective: Vasospasm remains the major cause of mortality and morbidity after subarachnoid hemorrhage. The standard therapy remains hypertension and hypervolemia (HH-T) and oral application of nimodipine. When patients deteriorate despite maximum HH-T, the intra arterial application of nimodipine is a viable treatment option we use in our neurosurgical ICU. We report about our experience with this method and the outcome results of 20 patients.

Method: Patients suffering from severe cerebral vasospasm confirmed in cerebral angiography were included in this study. Multimodal neuromonitoring was established and when cerebral oxygenation (PbtO₂) and blood flow (CBF) could not be kept above ischemic levels by maximum conservative treatment, continuous intra-arterial nimodipine application was started. Infusion rate and HH-T was adjusted according to PbtO₂ and CBF values. Outcome was assessed using the Glasgow Outcome Scale at time of hospital discharge and after 6 months.

Results: 28 nimodipine applications were performed in 20 patients, since some patients received multiple treatments. Treatment time differed from 1-18 days with a median treatment time of about 6 days. We experienced no major complications and no treatment had to be stopped due to hypotension or elevated intracranial pressure. At time of hospital discharge 2 patients died, 10 patients were in the poor outcome group (GOS 2-3) and 8 showed good outcome (GOS 4-5). 6 months after discharge no additional patient died, 4 remained GOS 2-3 and a total of 14 patients showed good outcome (68%).

Conclusions: We found the result of about 68 % good outcome in patients suffering from severe vasospasm really promising since it represents an improvement if compared to retrospective results in our clinic without intra-arterial nimodipine application. Thus we believe this method is feasible and beneficial for patients despite being an off label use and very elaborate as well as cost intensive.