Novel Mechanism of Intrathecal Nicardipine Delivery in Aneurysmal Subarachnoid Hemorrhage (aSAH)
Kimberly DiManna1, Elena Salikhova-Neace1, Alyssa Wicknick1, Katie Higgins1, Ian Rankine1, Jonathan Kleinman2, Ian Kaminsky3
1HCA HealthOne Neurology, 2BlueSky Neurology, 3RIA
Objective:
Present novel mechanism of intrathecal nicardipine delivery in aneurysmal subarachnoid hemorrhage (aSAH).
Background:
Vasospasm after aSAH can cause delayed cerebral ischemia (DCI) which increases mortality and morbidity. Several studies have demonstrated improved radiographic and clinical outcomes for patients treated with intrathecal nicardipine administered through extraventricular drains (EVDs). To our knowledge, intrathecal nicardipine has not been reported/administered via lumbar drain (LD) in patients without EVD but severe vasospasm.
Design/Methods:
IT nicardipine was administered via LD every 8 hours followed by irrigation with 2 cc preservative free saline, post infusion the patient remained supine for 4 hours with the LD clamped. When the LD was unclamped, 5 cc were drained per hour.
Results:
A 33 year old woman presented with severe headache, CT scan was interpreted as normal and she was discharged home after symptomatic headache treatment. Five days later she returned with altered mentation, severe aphasia, and a national institute of health stroke scale (NIHSS) of 23. Head CT demonstrated SAH without hydrocephalus. CTA demonstrated severe diffuse vasospasm and a small anterior communicating artery aneurysm. She underwent coiling and treatment of severe vasospasm with balloon angioplasty and intra-arterial verapamil. Her severe vasospasm continued and a decision was made to place a LD for intrathecal nicardipine. Her radiographic vasospasm stabilized/improved post intrathecal nicardipine administration. She underwent 15 intrathecal nicardipine administrations and was additionally started on intravenous milrinone in addition to standard of care for persistent severe vasospasm over 22 days in the ICU. She was discharged with an NIHSS of 6.
Conclusions:
Intrathecal nicardipine was safely administered 15 times through the LD with improved radiographic vasospasm.