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Intra-arterial Nimodipine and intra-venous Milrinone for management of delayed cerebral ischemia following aneurysmal subarachnoid haemorrhage

Author: KOTWAL Abhishek

Learn about a study comparing intra-arterial Nimodipine and intra-venous Milrinone for the management of delayed cerebral ischemia in this presentation from Dr. Abhishek Kotwal (Neuroradiology, NIMHANS, India).

Monday 14 March 2022
  • Case

    CASE PRESENTATION

    • Delayed cerebral ischemia (DCI) is one of the commonest causes of mortality and morbidity in patients with aneurysmal subarachnoid haemorrhage (SAH).
    • Various forms of chemical angioplasty protocols are being practiced as a part of care in DCI.
    • In the current study, two established chemical angioplasty protocols [intra-arterial nimodipine (IAN) and intra-venous milrinone (IVM)] were compared in terms of clinical improvement and appearance of new cerebral infarcts.

     

    METHODS

    • Prospective observational study
    • Adult aneurysmal subarachnoid haemorrhage patients admitted between July 2020 and June 2021
    • Patients who received either IAN or IVM were included 
    • Patients who received both IAN and IVM and/ or who underwent mechanical angioplasty were excluded.

     

    IAN PROTOCOL

    • The drug was injected daily in the involved cervical carotid or vertebral artery
    • In the angiosuite
    • 3mg (15 ml) diluted with normal saline (NS) to 50ml
    • Infused over 30min
    • For 5-7 days

     

    IVM PROTOCOL

    • The drug was given as a continuous intravenous infusion
    • 10 ml diluted with NS to 50ml
    • started at 7ml/hr, with titration according to clinical status, maximum 15 ml/hour
    • For 5-7 days
    • In the ICU.

     

    OUTCOMES AT THE END OF THERAPY

    • Clinical improvement: improvement in GSC by at least 2 points
    • CT/MRI: development of new infarcts
    • Statistical analysis: Chi-square test is used

     

    RESULTS

    • Thirty-four patients fulfilled inclusion criteria [13/34(38.2%) IVM, 21/34(61.7%) IAN].

     

    SAH

     

    GCS AT PRESENTATION

    • Patients in the IVM group(vs IAN group) had poorer median GCS (12 vs13).
    SAH

     

    MOTOR RESPONSE AT PRESENTATION

    • Patients in IVM group(vs IAN group) had poorer motor response[<M6 response,5/13(38.4%)vs5/21(23.8%),p=0.36]

       

    SAH

     

     

    MODIFIED FISHER GRADES OF SAH AT PRESENTATION

    • Patients in IVM group(vs IAN group) had higher grades [modified Fisher ≥3) of SAH {12/13(92.3%)vs8/21(85.7%),p=0.56}].

       

    SAH

     

    CLINICAL IMPROVEMENT

    • After the end of the therapy, more patients in the IAN group(vs IVM group) showed clinical improvement [17/21(80.9%)vs10/13(76.9%),p=0.77].

       

    SAH

     

    DEVELOPMENT OF NEW INFARCTS

    • After the end of the therapy, more patients in the IAN group(vs IVM group) showed the development of new infarcts[15/21(71.4%)vs7/13(53.8%),p=0.29] on the last CT/MRI.

       

    SAH

     

     

    DISCHARGED TO HOME

    • After the end of the therapy, more patients in the IAN group(vs IVM group) were discharged to home[13/21(61.9%)vs6/13(46.1%),p=0.36]

       

    SAH

     

    MORTALITIES AT DISCHARGE

    • After the end of the therapy, patients in IAN group(vs IVM group) had less mortalities[2/21(9.5%)vs3/13(23.0%),p=0.027].

       

    SAH

     

    LIMITATIONS

    • Single-center study
    • Small sample size
    • Different routes for administration hence different pharmacokinetics of the both the drugs
    • Selection bias- poorer initial GCS and higher SAH grades in Milrinone group at presentation

     

    CONCLUSION

    • In this single-center study, Intra-arterial nimodipine proved to be marginally better than intravenous milrinone for management of delayed cerebral ischemia following aneurysmal subarachnoid haemorrhage.
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