Effect of intra-arterial nimodipine in patients with subarachnoid hemorrhage and refractory vasospasm: a pilot study

Background

Vasospasm following subarachnoid hemorrhage (SAH) after rupture of a cerebral aneurysm is a major complication. If left untreated it leads to death or permanent deficits in over 20% of patients. Treatment includes triple H therapy and nimodipine given by the enteral route. In severe cases, angioplasty and superselective intra-arterial injection of vasodilators may be effective.

Objective

To evaluate the effect on transcranial Doppler (TCD) velocities of the treatment of moderate to severe refractory vasospasm with intra-arterial nimodipine.

Methods

Three patients with Fischer IV SAH after aneurysm rupture were treated with coil embolization in the first 3 days after the hemorrhagic event, and enteral nimodipine (360 mg/day) developed moderate to severe vasospasm on the middle cerebral artery (detected by TCD) refractory to triple H therapy. They were treated with superselective injection of intra-arterial nimodipine, infused during a period of 30 min–1 hour, and were evaluated after 12–24 hours by a new TCD.

Results

All three patients showed a reduction of mean flow velocity greater than 30% and a Lindergaard ratio lower than 3.

Conclusions

This is a small series of patients but it suggests that treatment with intra-arterial nimodipine may be effective in reducing the severity of vasospasm refractory to clinical therapy. We intend to increase our cohort and correlate these effects with the development of ischemia and neurological outcome.