The use of intravenous Milrinone to treat cerebral vasospasm following traumatic subarachnoid hemorrhage

Interventional Treatment of Symptomatic Vasospasm in the Setting of Traumatic Brain Injury: A Systematic Review of Reported Cases

Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies.

Management of refractory bacterial meningitis-associated cerebral vasospasm: illustrative case

BACKGROUND

Cerebral vasospasm is an alarming complication of acute bacterial meningitis with potentially devastating consequences. It is essential for providers to recognize and treat it appropriately. Unfortunately, there is no well-established approach to the management of postinfectious vasospasm, which makes it especially challenging to treat these patients. More research is needed to address this gap in care.

OBSERVATIONS

Here, the authors describe a patient with postmeningitis vasospasm that was refractory to induced hypertension, steroids, and verapamil. He eventually responded to a combination of intravenous (IV) and intra-arterial (IA) milrinone followed by angioplasty.

LESSONS

To our knowledge, this is the first report of successfully using milrinone as vasodilator therapy in a patient with postbacterial meningitis-associated vasospasm. This case supports the use of this intervention. In future cases of vasospasm after bacterial meningitis, IV and IA milrinone should be trialed earlier with consideration of angioplasty.

Neuroprotective Effects of Milrinone on Acute Traumatic Brain Injury

BACKGROUND

Traumatic brain injury is still an important health problem worldwide. Traumatic brain injury not only causes direct mechanical damage to the brain but also induces biochemical changes that lead to secondary nerve cell loss. In this study, we investigated the neuroprotective effect of milrinone after traumatic brain injury (TBI) in a rat model.

METHODS

Forty male Wistar albino rats, were used. Rats were divided into 4 groups: 1) sham, 2) TBI, 3) TBI + Ringers, and 4) TBI + Milrinone. In group 1 (sham), only craniotomy was performed. In group 2 (TBI), TBI was performed after craniotomy. In group 3 (TBI + Ringer), TBI was performed after craniotomy and intraperitoneal Ringers solution was given immediately afterward. Group 4 (TBI + Milrinone), TBI was performed after craniotomy, and milrinone was given 1.0 mg/kg milrinone intraperitoneally directly (0.5 mg/kg milrinone intraperitoneally again 24 hours, 48 hours, and 72 hours after trauma). Tests were performed for neurological and neurobehavioral functions. Immunohistochemistry and histopathology studies were performed.

RESULTS

In group 4 compared with group 2 and group 3 groups, tests for neurological functions and neurobehavioral functions were significantly better. In the milrinone treatment used in group 4, plasma and brain tissue tumor necrosis factor, 8-OH 2-deoxyguanosine , and interleukin 6 levels were significantly decreased, and increased plasma and tissue IL-10 levels were detected. Histopathological spinal cord injury and apoptotic index increased in groups 2 and 3, while significantly decreasing in group 4.

CONCLUSIONS

This study shows for the first time that the anti-inflammatory, antioxidant and antiapoptotic properties of milrinone may be neuroprotective after TBI.

Kinetics of cerebral blood flow velocities during treatment for delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

BACKGROUND

In aneurysmal subarachnoid hemorrhage (aSAH), one of the main determinants of prognosis is delayed cerebral ischemia (DCI). Transcranial Doppler (TCD) is used to monitor vasospasm and DCI. We aimed to better understand cerebral hemodynamics response to hypertension induction (HI) with norepinephrine (NE) and inotropic therapy with milrinone so that TCD can be a bedside tool in helping to guide DCI therapies. Our primary objective was to determine TCD blood flow velocity (BFV) kinetics during HI and inotropic therapy for DCI treatment. Secondly, we performed an analysis by treatment subgroups and evaluated clinical response to therapies.

METHODS

We performed a prospective observational cohort study in a Brazilian high-volume center for aSAH. Patients with aSAH admitted between 2016 and 2018 who received NE or milrinone for DCI treatment were included. TCDs were performed before therapy initiation (t0) and 45 (t1) and 90 min (t2) from the onset of therapy. For each DCI event, we analyzed the highest mean flow velocity (MFV) and the mean MFV and compared their kinetics over time. The National Institutes of Health Stroke Scale was determined at t0, t1, and t2.

RESULTS

Ninety-eight patients with aSAH were admitted during the study period. Twenty-one (21.4%) developed DCI, of whom six had DCI twice, leading to a total of 27 analyzed DCI events (12 treated with HI and 15 with milrinone). Patients treated with NE had their mean arterial pressure raised (85 mm Hg in t0, 112 mm Hg in t2 [p < 0.001]), whereas those treated with milrinone had a significant decrease in mean arterial pressure over treatment (94 mm Hg in t0, 88 mm Hg in t2 [p = 0.004]). Among all treated patients, there was a significant drop from t0 to t2 but not to t1 in the highest MFV and in the highest mean MFV. Among those treated with HI, there were no significant changes from t0 to t1 or t2 (highest MFV in t0 163.2 cm/s, in t1 172.9 cm/s [p = 0.27], and in t2 164 cm/s [p = 0.936]). Conversely, in those treated with milrinone, there was a significant decrease from t0 to t1 and to t2 (highest MFV in t0 197.1 cm/s, in t1 172.8 cm/s [p = 0.012], in t2 159 cm/s [p = 0.002]). Regarding clinical outcomes, we observed a significant improvement in mean National Institutes of Health Stroke Scale scores from 17 to 16 in t1 (p < 0.001) and to 15 in t2 (p = 0.002).

CONCLUSIONS

BFV analyzed by TCD in patients with aSAH who developed DCI and were treated with milrinone or NE significantly decreased in a time-dependent way. Milrinone effectively decrease cerebral BFV, whereas NE do not. Clinical improvement was achieved with both treatment strategies.

Efficacy and safety of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage: a systematic review

Objective

To systematically review the current evidence on the efficacy of milrinone in the treatment of cerebral vasospasm after subarachnoid hemorrhage.

Methods

The Pubmed^®, Cochrane and Embase databases were screened for articles published from April 2001 to February 2019. Two independent reviewers performed the methodological quality screening and data extraction of the studies.

Results

Twenty-two studies were found to be relevant, and only one of these was a randomized control trial. Studies showed marked heterogeneity and weaknesses in key methodological criteria. Most patients presented with moderate to severe vasospasm. Angiography was the main method of diagnosing vasospasm. Intra-arterial administration of milrinone was performed in three studies, intravenous administration was performed in nine studies, and both routes of administration in six studies; the intrathecal route was used in two studies, the cisternal route in one study and endovascular administration in one study. The side effects of milrinone were described in six studies. Twenty-one studies indicated resolution of vasospasm.

Conclusion

The current evidence indicates that milrinone may have a role in treatment of vasospasm after aneurysmal subarachnoid hemorrhage. However, only one randomized control trial was performed, with a low quality level. Our findings indicate the need for future randomized control trials with patient-centered outcomes to provide definitive recommendations.

[Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]

BACKGROUND

Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage.

METHODS

The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day^-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg^-1.min^-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s^-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%).

RESULTS

The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012).

CONCLUSIONS

The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

[Effect of magnesium sulphate and milrinone on cerebral vasospasm after aneurysmal subarachnoid hemorrhage: a randomized study]

BACKGROUND

Aneurysmal subarachnoid hemorrhage is an important cause of premature death and disability worldwide. Magnesium sulphate is shown to have a neuroprotective effect and it reverses cerebral vasospasm. Milrinone is also used in the treatment of cerebral vasospasm. The aim of the present study was to compare the effect of prophylactic magnesium sulphate and milrinone on the incidence of cerebral vasospasm after subarachnoid hemorrhage.

METHODS

The study included 90 patients with aneurysmal subarachnoid hemorrhage classified randomly (by simple randomization) into two groups: magnesium sulphate was given as an infusion of 500mg.day^-1 without loading dose for 21 days. Group B: milrinone was given as an infusion of 0.5μg.kg^-1.min^-1 without loading dose for 21 days. The cerebral vasospasm was diagnosed by mean cerebral blood flow velocity in the involved cerebral artery (mean flow velocity≥120cm.s^-1), neurological deterioration by Glasgow coma scale, or angiography (the decrease in diameter of the involved cerebral artery >25%).

RESULTS

The mean cerebral blood flow velocity decreased significantly in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p<0.001). The incidence of cerebral vasospasm decreased significantly with magnesium compared to milrinone (p=0.007). The Glasgow coma scale significantly improved in the magnesium group compared to milrinone group through Day 7, Day 14 and Day 21 (p=0.036, p=0.012, p=0.016, respectively). The incidence of hypotension was higher with milrinone than magnesium (p=0.012).

CONCLUSIONS

The incidence of cerebral vasospasm after aneurysmal subarachnoid hemorrhage was significantly lower and Glasgow coma scale significantly better with magnesium when compared to milrinone. Milrinone was associated with a higher incidence of hypotension and requirement for dopamine and norepinephrine when compared to magnesium.

Chemical angioplasty with spasmolytics for vasospasm after subarachnoid hemorrhage

BACKGROUND

Clinically symptomatic vasospasm leading to delayed ischemic neurological deficits occurs in up to 30% of patients with subarachnoid hemorrhage (SAH). Vasospasm can result in a serious decline in clinical conditions of patients with SAH, yet the algorithm for vasospasm treatment and prevention remains unclear. Intra-arterial administration of vasodilators is one of the modalities used for vasospasm therapy.

METHODS

Over the last 7 years, we have treated 27 female and 7 male patients with vasospasm using intra-arterial administration of either nimodipine or milrinone; all had suffered aneurysm rupture. Of these patients, 28 were treated surgically (clip), and 6 patients had their aneurysm coiled. Spasmolytics were applied from day 2 to day 18 after rupture.

RESULTS

Of the 53 procedures, angiographic improvement was documented in 92% of cases with a mean flow velocity decrease of 65 cm/s. Brain metabolism changes were monitored after the procedure. The highest level of immediate clinical improvement was observed in conscious patients with a focal neurological deficit (aphasia, hemiparesis). Overall clinical outcomes (Glasgow outcome scale, GOS) were as follows: GOS 5 (12 patients), GOS 4 (5 patients), GOS 3 (5 patients), GOS 2 (6 patients), and GOS 1 (6 patients).

CONCLUSIONS

Intra-arterial administration of spasmolytics is a safe and potent method of vasospasm treatment. It is most effective when applied to conscious patients with a focal deficit. For unconscious patients, its therapeutic benefits are inconclusive. Patients in severe clinical states would further require use of other diagnostic tools such as multimodal brain monitoring to complement vasospasm therapy.

The Use of Milrinone in Patients with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Systematic Review

OBJECTIVE

The purpose of this article is to provide a systematic review of the evidence supporting the use of milrinone for the management of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH).

DESIGN

Primary outcomes were functional neurological status and the incidence of cerebral infarction. Search strategies adapted to the different databases were developed by a professional librarian. Medline, EMBASE, the Cochrane Library database, Web of Science, SCOPUS, BIOSIS, Global Health, Health Star, Open SIGLE, Google Scholar and the New York Academy of Medicine Gray Literature were searched as well as clinical trials databases and the proceedings of several scientific meetings. Quality of the evidence for these outcomes across studies was adjudicated using the GRADE Working Group criteria.

RESULTS

The search resulted in 284 citations after elimination of duplicates. Of those 9 conference proceedings and 15 studies met inclusion criteria and consisted of case reports, case series and two comparative studies: one non-randomized study with physiological outcomes only and a case series with historical controls. There was considerable variation in dosing and in co-interventions and no case control or randomized controlled studies were found.

CONCLUSION

There is currently only very low quality evidence to support the use of milrinone to improve important outcomes in patients with delayed cerebral ischemia secondary to subarachnoid hemorrhage. Further research is needed to clarify the value and risks of this medication in patients with SAH.