Assistant Professor Boston Children’s Hospital / Harvard Medical School Boston, MA, US
Disclosure(s):
Alfred See, MD: No financial relationships to disclose
Introduction: Subarachnoid hemorrhage (SAH) is responsible for around 5% of all stroke types worldwide, with cerebral vasospasm occurring in approximately 70% of these patients, precipitating delayed cerebral ischemia, a significant morbidity and mortality factor. This investigation evaluates the clinical efficacy and safety profiles of intra-arterial milrinone versus nicardipine in managing cerebral vasospasm following SAH.
Methods: We retrospectively reviewed a cohort of patients aged 18-80 years diagnosed with non-traumatic aneurysmal SAH who underwent intra-arterial vasodilator therapy. Patients were divided into groups receiving milrinone or nicardipine as intra-arterial vasospasm treatments. Outcomes measured included time to first intervention, vasospasm recurrence, adverse events, hospital length of stay (LOS), and modified Rankin score at discharge. Multivariate logistic regression analyzed pre-existing conditions linked with recurrent vasospasm post-treatment.
Results: A total of 57 patients were enrolled in the study, with a median age of 56 years, exhibiting a slight male predominance (54%). Patients treated with milrinone had a statistically significant reduction in the incidence of recurrent vasospasm (p=0.03) and demonstrated better functional outcomes as indicated by modified Rankin scores at discharge (p=0.008) compared to those receiving nicardipine. Conversely, the milrinone group experienced a higher rate of cardiovascular adverse events, although the difference was not statistically significant when compared with nicardipine (p=0.5). Hazard ratios adjusted for pre-existing conditions suggested a reduced likelihood of vasospasm recurrence with milrinone treatment (HR 0.13 [0.01-0.75], p=0.037). Neurological adverse events, the Lindegaard ratio used to differentiate vasospasm from hyperemia, and the duration of hospital stay did not significantly differ between treatment modalities.
Conclusion : Intra-arterial milrinone administration appears to be a more effective option in reducing the recurrence of cerebral vasospasm post-SAH, with an improvement in functional outcomes at discharge. However, IA milrinone is associated with a higher frequency of cardiovascular adverse events compared to treatments with verapamil/nicardipine.
