gms | German Medical Science

Objective: Delayed cerebral ischemia (DCI) is a frequently occurring complication in patients with aneurysmal subarachnoid hemorrhage (aSAH), that may lead to disabling neurological deficits or death despite maximal intensive care therapy. Multiple factors may contribute to DCI with vasospasm of large intracranial vessels being the most widely recognized. Continuous intraarterial nimodipine infusion (CIAN) represents a promising therapeutic option in severe cases of DCI, which are refractory to standard therapy. We report our experience with CIAN in 17 of such cases.

Methods: CIAN was initiated and ended based on an individual interdisciplinary evaluation of the clinical and diagnostic course of the patient using transcranial Doppler, CT angiography (CTA), CT perfusion (CTP) and digital subtraction angiography (DSA). One or two microcatheters were placed into the internal carotid or vertebral artery according to the site and severity of vasospasm. Nimodipine (NDP) was administered continuously in a rate of 0.5 - 2 mg/h. During CIAN, intensive care including ICP/CPP-measuring was conducted. The therapeutic effect was measured by evaluating the Glasgow Outcome Scale (GOS) at discharge and within 1 year after aSAH and by occurrence of infarctions in subsequent CT/MRI-scans.

Results: In the period of May 2016 to January 2018, 17 patients received CIAN. The median treatment onset of CIAN was 9 (3-13) days; the median duration was 5 (1–13) days. Favorable outcome (GOS 4 or 5) was achieved in 9 patients (53%) at discharge and in 13 patients within 1 year (76%). Follow-up imaging showed minor cerebral infarction in 5 and major infarction in 3 patients. One patient developed a localized cerebral edema as a possible side effect. One patient died due to malignant posthemorrhagic edema. Normalization of CTP-parameters within 2 days was observed in 9/17 patients. The remaining 6 patients showed clinical response and thus did not receive short-term CTP imaging.

Conclusion: CIAN is a feasible, safe and effective therapeutic option for patients with severe therapy-refractory delayed cerebral ischemia. Our results concerning the outcome within one year are in line with previously published retrospective studies. The study is limited by its retrospective character, the lack of a control group and the small number of patients. A prospective randomized clinical trial is needed to confirm the positive retrospective results of this study and previously published studies.