Single Center Experience of Intrathecal Nicardipine Use in The Treatment of Vasospasm- Lessons Learned
Aaisha Mozumder1, Anqi Luo2, Davana Ramaswamy2, Shadman Sakib Mozumder3, Firas Kaddouh2
1Mount Sinai Hospital, 2UT Health San Antonio, 3University of Texas at Dallas
Background:
Cerebral vasospasm and delayed cerebral ischemia (DCI) following aneurysmal SAH leads to significant morbidity and mortality. Intrathecal (IT) nicardipine has been shown to improve outcome and reduce DCI. We sought to study our limited experience with this treatment modality, in order to potentially inform our practice in treating vasospasm.
Design/Methods:
Retrospective case series of all patients who received IT nicardipine for the treatment of cerebral vasospasm from 2016 to 2021 at our University Hospital. Demographics, risk factors, clinical course and outcomes were analyzed.
Results:
12 patients received intrathecal nicardipine. Linear regression analysis showed that IT nicardipine was associated with a reduction of the mean cerebral blood flow velocity of 16%. 5 patients had in-hospital mortality; 4 out of these 5 patients developed in-hospital DCI. Age (p 0.017), history of hypertension(HTN) (p 0.0007) were significant predictors for in-hospital mortality. 6 patients developed DCI: mFisher scale (p 0.03), admission GCS (p 0.000998), vasopressor requirement to maintain target pressure (p 0.04) were significant predictors for DCI. 1 patient was diagnosed with bacterial ventriculitis. 80% patients had a favorable functional outcome (mRS≤2) at 90 days.
Conclusions:
The choice of this treatment on a case-by-case basis somewhat has led to rendering it as a salvage treatment at our center. In our cohort, we found significant mortality rate, with age and HTN as predictive factors for in-hospital mortality, and mFisher scale, admission GCS and vasopressor usage as predictors for DCI. These results can be difficult to interpret, especially that we used it in only few selected patients with initial comorbidities potentially confounding the high mortality and morbidity.
Intrathecal nicardipine treatment without a well-vetted protocol can potentially misinform the practice style and lead to early abandonment of this promising therapy as part of our armamentarium. Thus, it is important to develop a standardized protocol before deploying in clinical practice.