Continuous intraarterial nimodipine therapy in SAH patients with refractory DCI – Risk factors for unfavorable outcome
Elena Kurz (Mainz), Carolin Brockmann (Mainz), Darius Kalasauskas (Mainz), Florian Ringel (Mainz), Axel Neulen (Mainz)
Continuous intraarterial nimodipine infusion (CIAN) is a rescue therapy in subarachnoid hemorrhage (SAH) patients with refractory delayed cerebral ischemia (DCI). However, the benefit of this therapy is variable and complications have to be taken into account. The objective of this study was to evaluate risk factors for complications and identify predictors for outcome.
Retrospective single center study, including all SAH patients treated from 2016 - 2023 who received CIAN. CIAN was indicated in patients with DCI refractory to induced hypertension, and ended based on improvement of clinical symptoms, and resolving vasospasms and normalizing perfusion. For CIAN, microcatheters were placed in the internal carotid (ICA) or vertebral arteries, Nimodipine was administered continuously. Demographic data, aneurysm location, WFNS and Fisher score, need for a CSF-drain, radiological response to CIAN, CIAN-associated complications, DCI-related infarctions as well as outcome after 6 months(mRS) were evaluated.
36 patients (27 female, 9 male) with a mean age of 53.1 years (SD=12.2) were included. 11 patients had a complication related to CIAN. The most frequent complication was formation of a thrombus blocking the catheter (n=5). The Fisher and WFNS scores of CIAN patients were 3.6 (SD=0.6) and 3.1(SD=1.6), respectively. Mean mRS after 6 months was 3.2 (SD=2.1), good outcome (mRS 0-3) was found in 15 patients, unfavorable (mRS 4-6) in 21. DCI-associated infarctions were found in 21 patients. 16 cases showed an excellent response with resolving vasospasms. In 20 patients CIAN was not able to completely resolve vasospasm. Incompletely resolving vasospasm was associated with high WFNS (p=0.03, OR=1.7; multivariate analysis), multiple aneurysms (p=0.03, OR=5.3) and the need for CIAN in both ICA (p=0.05, OR=2.6), and was a risk factor for unfavorable 6 months outcome (p=0.028; OR=5.0), additionally to a high Fisher score (p=0.028; OR=4.7) and the need for an EVD (p=0.019; OR=8.3). Complications related to the procedure had no influence on outcome (p=0.5) or development of infarctions (p=0.6).
CIAN is a promising method for treating SAH patients with refractory DCI, with excellent response in many cases (44% in our cohort). We found no evidence that CIAN-related complications affected outcome. Based on the risk factors for unfavorable outcome identified here, more studies are warranted to determine which subgroups of SAH patients benefit most from CIAN
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