Intrathecal nicardipine as treatment for severe cerebral vasospasm after aneurysmal subarachnoid hemorrhage: A retrospective clinical study

Abstract

Abstract Object: Vasospasm and delayed cerebral ischemia (DCI) are complications of aneurysmal subarachnoid hemorrhage (aSAH) and contributing to up to 23% of the disability and deaths from aSAH. The use of intrathecal nicardipine as a possible treatment modality for DCI has been explored with mixed results. We present a retrospective series comparing standard post-aSAH care to standard care plus intrathecal nicardipine therapy. The primary objective of this study was to assess for any difference in functional outcome in terms of modified Rankin score (mRS) between the standard therapy group and intrathecal nicardipine group at discharge and 1 month. Methods: Institutional Review Board (IRB) approval was obtained for a retrospective chart review of patients with aneurysmal subarachnoid hemorrhage (aSAH) who were treated at the University of Mississippi Medical Center between January 2012 and June 2019. Inclusion criteria included sufficient available medical documentation, aneurysmal subarachnoid hemorrhage with documentation of an intracranial aneurysm and age ≥ 18. Exclusion criteria included non-aneurysmal subarachnoid hemorrhage, patients with insufficient medical records, and mycotic aneurysms. The decision to treat with intrathecal nicardipine was based on the individual practice of a single neuro-intensivist in collaboration with the neurosurgical staff. Results: A total of 385 patients were included in the study with 31 patients receiving intrathecal nicardipine. Those within the nicardipine group presented with significantly worse Hunt and Hess grades and experienced significantly worse cerebral vasospasm, higher TCD velocities, higher rates of DCI, and higher rates of hydrocephalus. When controlling for placement of an external ventricular drain, the patients in the intrathecal nicardipine group experienced higher rates of ventriculitis (10% vs. 2%, p < 0.05). There was no significant difference in ICU stay or hospital stay, mRS at discharge, or at 1 month follow up between the two groups. Conclusion: In our series, intrathecal nicardipine therapy did not significantly alter outcomes in terms of mRS at discharge or at 1 month. There was, however, a significant increase in ventriculitis among patients who received this therapy.