Milrinone for refractory cerebral vasospasm with delayed cerebral ischemia

Area of Science:

• Neurology
• Neurosurgery
• Critical Care Medicine

Background:

• Cerebral vasospasm and delayed cerebral ischemia (DCI) are critical complications following aneurysmal subarachnoid hemorrhage (aSAH).
• Intravenous (IV) milrinone shows promise for treating vasospasm/DCI, but data on refractory cases are limited.
• Predictors and outcomes of rescue therapies for refractory vasospasm/DCI require further investigation.

Purpose of the Study:

• To identify predictors of vasospasm/DCI refractory to standard IV milrinone therapy after aSAH.
• To analyze the efficacy of rescue therapies, including intraarterial (IA) milrinone and mechanical angioplasty.
• To evaluate the safety and effectiveness of aggressive milrinone use in managing vasospasm/DCI.

Main Methods:

• Retrospective cohort study of 322 patients with aSAH (2010-2016).
• Patients stratified into no DCI, standard therapy, and rescue therapy groups.
• Primary outcome: DCI-related cerebral infarction; Secondary outcomes: functional outcome (mRS), vasospasm reversal.

Main Results:

• Nineteen percent (21/110) of patients required rescue therapy for refractory vasospasm/DCI.
• IA milrinone reversed vasospasm in 32% of treated vessels, with 76% showing neurological improvement within 24 hours.
• Moderate/severe vasospasm independently predicted the need for rescue therapy (OR 27).
• Overall favorable functional outcome (mRS 0-2) was achieved in 65% of patients, with no significant difference between groups.

Conclusions:

• Aggressive use of milrinone, including IA administration, is safe and effective for vasospasm/DCI post-aSAH.
• Intraarterial milrinone and mechanical angioplasty represent valuable rescue options for refractory vasospasm.
• Further research should focus on optimizing treatment strategies for vasospasm/DCI in aSAH patients.