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Jentzsch J, Ziganshyna S, Lindner D, Merkel H, Mucha S, Schob S, Quäschling U, Hoffmann KT, Werdehausen R, Halama D, Gaber K, Richter C. Nimodipine vs. Milrinone – Equal or Complementary Use? A Retrospective Analysis. Front Neurol 2022; 13:939015. [PMID: 35911878 PMCID: PMC9330364 DOI: 10.3389/fneur.2022.939015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cerebral vasospasm (CVS) continues to account for high morbidity and mortality in patients surviving the initial aneurysmal subarachnoid hemorrhage (SAH). Nimodipine is the only drug known to reduce delayed cerebral ischemia (DCI), but it is believed not to affect large vessel CVS. Milrinone has emerged as a promising option. Our retrospective study focused on the effectiveness of the intra-arterial application of both drugs in monotherapy and combined therapy. Methods We searched for patients with aneurysmal SAH, angiographically confirmed CVS, and at least one intra-arterial pharmacological angioplasty. Ten defined vessel sections on angiograms were assessed before and after vasodilator infusion. The improvement in vessel diameters was compared to the frequency of DCI-related cerebral infarction before hospital discharge and functional outcome reported as the modified Rankin Scale (mRS) score after 6 months. Results Between 2014 and 2021, 132 intra-arterial interventions (144 vascular territories, 12 bilaterally) in 30 patients were analyzed for this study. The vasodilating effect of nimodipine was superior to milrinone in all intradural segments. There was no significant intergroup difference concerning outcome in mRS (p = 0.217). Only nimodipine or the combined approach could prevent DCI-related infarction (both 57.1%), not milrinone alone (87.5%). Both drugs induced a doubled vasopressor demand due to blood pressure decrease, but milrinone alone induced tachycardia. Conclusions The monotherapy with intra-arterial nimodipine was superior to milrinone. Nimodipine and milrinone may be used complementary in an escalation scheme with the administration of nimodipine first, complemented by milrinone in cases of severe CVS. Milrinone monotherapy is not recommended.
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Affiliation(s)
- Jennifer Jentzsch
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | | | - Dirk Lindner
- Department of Neurosurgery, Leipzig University Hospital, Leipzig, Germany
| | - Helena Merkel
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Simone Mucha
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
| | - Stefan Schob
- Department of Radiology, Halle University Hospital, Halle, Germany
| | - Ulf Quäschling
- Department of Radiology, Kantonsspital Baselland, Liestal, Switzerland
| | | | - Robert Werdehausen
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Dirk Halama
- Department of Oral and Maxillofacial Surgery, Leipzig University Hospital, Leipzig, Germany
| | - Khaled Gaber
- Department of Neurosurgery, Leipzig University Hospital, Leipzig, Germany
| | - Cindy Richter
- Department of Neuroradiology, Leipzig University Hospital, Leipzig, Germany
- *Correspondence: Cindy Richter
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Isola C, Evain JN, Francony G, Baud C, Millet A, Desrumaux A, Wroblewski I, Payen JF, Mortamet G. Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management. Neurocrit Care 2021; 36:868-875. [PMID: 34791595 DOI: 10.1007/s12028-021-01388-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). METHODS This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). RESULTS Eighty patients aged 8.6 years (3.3-14.8 years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). CONCLUSIONS These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.
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Affiliation(s)
- Clément Isola
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Jean-Noel Evain
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France
| | - Gilles Francony
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France
| | - Caroline Baud
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Anne Millet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Amélie Desrumaux
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Jean-Francois Payen
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France.,Grenoble Institute Neurosciences, Grenoble Alpes University, Grenoble, 3800, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France. .,INSERM U1042, Grenoble-Alpes University,, Grenoble, 3800, France.
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Chan AY, Choi EH, Yuki I, Suzuki S, Golshani K, Chen JW, Hsu FP. Cerebral vasospasm after subarachnoid hemorrhage: Developing treatments. BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Pereira AR, Sanchez-Peña P, Biondi A, Sourour N, Boch AL, Colonne C, Lejean L, Abdennour L, Puybasset L. Predictors of 1-year outcome after coiling for poor-grade subarachnoid aneurysmal hemorrhage. Neurocrit Care 2007; 7:18-26. [PMID: 17657653 DOI: 10.1007/s12028-007-0053-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe features in patients admitted to the intensive care unit (ICU) for poor-grade aneurysmal subarachnoid hemorrhage (SAH) and to identify predictors of 12-month outcome. METHODS We conducted a controlled observational study of 51 consecutive patients treated with endovascular coiling within 96 h of rupture for poor-grade aneurysmal SAH (20 men and 31 women, age 54 +/- 12 years). We recorded co-morbidities; initial severity; aneurysm location; occurrence of acute hydrocephalus, initial seizures, and/or neurogenic lung edema; troponin values, Fisher grade; computed tomography (CT) findings; treatment intensity; and occurrence of vasospasm. The brain injury marker S100B was assayed daily over the first 8 days. Glasgow Outcome Scores (GOS) were recorded at ICU discharge, at 6 and 12 months. The main outcome criterion was the 1-year GOS score, which we used to classify patients as having a poor outcome (GOS 1-3) or a good outcome (GOS 4-5). RESULTS Overall, clinical status after 1 year was very good (GOS 5) in 41% of patients and good (GOS 4) in 16%. Neither baseline characteristics nor interventions differed significantly between patients with good outcome (GOS 4-5) and those with poor outcome (GOS 1-3). Persistent intracranial pressure elevation and higher mean 8-day S100B value significantly and independently predicted the 1-year GOS outcome (P = 0.008 and P = 0.001, respectively). CONCLUSIONS Patients in poor clinical condition after SAH have more than a 50:50 chance of a favorable outcome after 1 year. High mean 8-day S100B value and persistent intracranial hypertension predict a poor outcome (GOS 1-3) after 1 year.
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Affiliation(s)
- Ana R Pereira
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Pierre and Marie Curie-Paris 6 University, Paris, France
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