High-Dose Intra-Arterial Nicardipine Results in Hypotension Following Vasospasm Treatment in Subarachnoid Hemorrhage

Abstract

Intra-arterial nicardipine is associated with significant intra-operative blood pressure lowering, an increased requirement for intra-operative vasopressor therapy, and a tendency toward re-treatment when used as initial monotherapy for vasospasm.

Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis

“…The dihydropyridines nimodipine and nicardipine were more commonly used than the phenylalkylamine class agent verapamil. Nicardipine is known to be associated with a significant risk of systemic hypotension,10 which can limit the maximum dose that can be given safely to patients with vasospasm who are dependent on high blood pressure to maintain cerebral perfusion. Papaverine was one of the earliest agents to be used as an IAD for vasospasm in aSAH.…”

Off-Label Use of Drugs and Devices in the Neuroendovascular Suite

“…31 Intra-arterial or intravenous use of verapamil, nimodipine (Nimotop), and nicardipine (Cardene; Baxter Healthcare, Deerfield, Illinois) have all been reported to be effective and safe in the treatment of cerebral vasospasm (category III). 10,[32][33][34][35] The offlabel use of calcium channel blockers in treating cerebral vasospasm is recognized as a generally accepted medical practice within the physician community; however, the treating physician must ensure that adequate hemodynamic monitoring is performed on patients receiving these agents. Low doses of intraarterial calcium channel blockers were not associated with significant hemodynamic changes, but high-dose nicardipine was associated with hypotension.…”

“…Low doses of intraarterial calcium channel blockers were not associated with significant hemodynamic changes, but high-dose nicardipine was associated with hypotension. 34 The duration of monitoring must be adequate on the basis of the half-life of the agent: verapamil (4 minutes), nimodipine (7 minutes), and nicardipine (3 minutes). Physicians must also be familiar with and prepared to address commonly observed adverse events of hypotension and bradycardia.…”

Invasive interventional management of post-hemorrhagic cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage

“…Monitoring of intracranial pressure should be strongly considered when multiple vascular territories are being treated by IAVT 34 35. Some interventional therapies may inadvertently lower systemic blood pressure and negatively impact cerebral perfusion 32 36. Consequently, a functional arterial line should be in place for continuous blood pressure monitoring in the neuroangiography suite.…”

“…Systemic hypotension is rarely seen with verapamil; however, doses exceeding 35 mg per procedure have been associated with significant decreases in mean arterial pressure, often in delayed fashion as long as 5–7 h after the procedure 32. Intra-arterial nicardipine is more often associated with hypotension, particularly with high doses 36 46 47. Initial reports of intra-arterial verapamil described doses of 2–5 mg per vessel treated.…”