Intrathecal nicardipine for symptomatic, refractory vasospasm treatment in pediatric patients: a case series

Vasospasm is a potentially devastating condition that can develop in pediatric patients secondary to traumatic, inflammatory, infectious, and neoplastic etiologies and carries a high risk of morbidity and mortality (Isola et al. 2022, Krishna et al. 2005). Management is often adapted from adult to pediatric care given its relative rarity in children. There is level 3 evidence for the use of intrathecal (IT) calcium channel blocker (nicardipine) administration to treat refractory vasospasm in the adult subarachnoid hemorrhage (SAH) population. Its use has yet to be investigated in children (Krishna et al. 2005). We aim to review the safety profile and efficacy of IT nicardipine for non-traumatic SAH with refractory vasospasm at our institution.

We present a single institution retrospective series of pediatric patients treated with IT nicardipine for symptomatic vasospasm refractory to standard therapies including oral nimodipine, hyperdynamic augmentation therapies, and targeted intra-arterial therapy.

Pediatric patients (n = 3), ages 16-17 years old, admitted with non-traumatic SAH who developed severe, symptomatic, and refractory vasospasm were included. All patients presented with SAH from ruptured aneurysms. A 5-day course of IT nicardipine was initiated using a protocol adapted from our adult cerebrovascular/neurocritical care service. Decreases in peak middle cerebral artery velocity (range 61-290 cm/s) and Lindegaard ratios (range 0.3-4.2) were observed from initiation to completion of treatment.

IT nicardipine for pediatric non-traumatic SAH with vasospasm refractory to standard treatments was used in our small series with no complications and no new ischemic events. Clinical and radiographic effects were encouraging. Further study is warranted.