Preliminary experience with intra-arterial nicardipine in patients with acute ischemic stroke

To report experience with intra-arterial (IA) calcium channel blocker (nicardipine) in patients with acute ischemic stroke with and without reteplase, mechanical thrombectomy (snare), and primary angioplasty to achieve maximal recanalization. Selective delivery of calcium channel blocker may improve perfusion and possibly provide neuroprotection in cerebral ischemia.

We performed a retrospective study to determine the angiographic and clinical outcomes among patients treated with IA nicardipine administered as 2.5-5 mg dose either alone or adjunct to intra-arterial thrombolysis. Mean arterial pressure and heart rate were recorded throughout the injection. Angiographic severity of initial occlusion and recanalization was assessed using the Qureshi grading scheme. Neurological examinations and computed tomographic scans were performed prior to, immediately, and 24 h after thrombolysis for each patient, to assess the neurological improvement and symptomatic or asymptomatic intracranial hemorrhages.

Ten patients median age of 60 years (age range: 35-93 years) were administered IA nicardipine. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 14 (range 6-19). All patients received IA nicardipine either in combination with thrombolytics (n = 6) or as monotherapy (n = 4). The average decrease in mean arterial pressure (MAP) was 10 mmHg; except one patient who had an asymptomatic decline of 34 mm Hg, which responded to fluid resuscitation. None of the patients suffered any procedural and post-procedural complication. Overall recanalization (improvement in one grade or greater) was observed in 2 of 10 patients with IA nicardipine with or without thrombolytic treatment. Other angiographic changes observed included improvement in collateral flow (n = 2), increase in transit time (n = 1), and vasodilation of distal arteries and branches (n = 4). No patient demonstrated any worsening from the baseline grade in response to IA nicardipine. Of the two patients who underwent serial magnetic resonance imaging (MRI) and one patient demonstrated reversal of pretreatment restricted diffusion. Neurological improvement defined by a decrease of four points or greater was observed in four patients at 24 h following treatment.

Intra-arterial delivery of nicardipine in doses up to 5 mg is well tolerated among patients with acute ischemic stroke. Further studies are required to determine the potential efficacy of this approach with or without thrombolytics.