Milrinone for the Treatment of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Fraticelli, Amanda; Cholley, Bernard; Losser, Marie-Reine; Maurice, Jean-Pierre Saint; Payen, Didier

doi:10.1161/strokeaha.107.492447

Cited by 148 publications

(98 citation statements)

References 24 publications

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“…Specific treatments to prevent and treat symptomatic vasospasm include nimodipine, hyperdynamic therapy with induced hypertension, augmentation of cardiac output using inotropic drugs, and intraarterial treatments such as luminal angioplasty and infusions of vasodilators such as nimodipine, verapamil, and milrinone. 14,32,36,38,42 Despite knowledge that these treatments are effective against vasospasm, these are underutilized due to the absence of real-time monitoring that may detect vasospasm in the presymptomatic phase. With daily TCD monitoring these specific treatments could begin earlier to not only treat symptomatic vasospasm but also prevent vasospasm from advancing to the symptomatic phase.…”

Section: Discussionmentioning

confidence: 99%

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Kumar¹,

Shahripour²,

Harrigan

2016

JNS

155

100

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C erebral vasospasm is a major cause of poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH), resulting in cerebral ischemia, infarction, disability, and death. 20,25 Cerebral vasospasm is noted on angiography in as many as 70% of patients following aSAH and is predicted by high mean flow velocities (MFVs) on transcranial Doppler (TCD) ultrasonography. 19,24,26,35 Vasospasm is strongly associated with delayed cerebral ischemia (DCI) 12 and cerebral infarction, 11,39,49 although poor outcomes can still occur in its absence. Of the current techniques available for diagnosing cerebral vasospasm, catheter angiography and CT angiography are invasive, and require contrast-dye injection and radiation exposure, and therefore do not allow dynamic monitoring of vasospasm. 31The radiation exposure and invasive nature of angiography implies that it is not useful for identifying subclinical vasospasm prior to the onset of the condition, and that its use is frequently restricted to confirm prevalent vasospasm abbreviatioNs aSAH = aneurysmal subarachnoid hemorrhage; CI = confidence interval; DCI = delayed cerebral ischemia; df = degrees of freedom; MFV = mean flow velocity; MWE = mean weighted estimate; NPV = negative predictive value; PPV = positive predictive value; TCD = transcranial Doppler. obJective The impact of transcranial Doppler (TCD) ultrasonography evidence of vasospasm on patient-centered clinical outcomes following aneurysmal subarachnoid hemorrhage (aSAH) is unknown. Vasospasm is known to lead to delayed cerebral ischemia (DCI) and poor outcomes. This systematic review and meta-analysis evaluates the predictive value of vasospasm on DCI, as diagnosed on TCD. methods MEDLINE, Scopus, the Cochrane trial register, and clinicaltrials.gov were searched through September 2014 using key words and the terms "subarachnoid hemorrhage," "aneurysm," "aneurysmal," "cerebral vasospasm," "vasospasm," "transcranial Doppler," and "TCD." Sensitivities, specificities, and positive and negative predictive values were pooled by a DerSimonian and Laird random-effects model. results Seventeen studies (n = 2870 patients) met inclusion criteria. The amount of variance attributable to heterogeneity was significant (I 2 > 50%) for all syntheses. No studies reported the impact of TCD evidence of vasospasm on functional outcome or mortality. TCD evidence of vasospasm was found to be highly predictive of DCI. Pooled estimates for TCD diagnosis of vasospasm (for DCI) were sensitivity 90% (95% confidence interval [CI] 77%-96%), specificity 71% (95% CI 51%-84%), positive predictive value 57% (95% CI 38%-71%), and negative predictive value 92% (95% CI 83%-96%). coNclusioNs TCD evidence of vasospasm is predictive of DCI with high accuracy. Although high sensitivity and negative predictive value make TCD an ideal monitoring device, it is not a mandated standard of care in aSAH due to the paucity of evidence on clinically relevant outcomes, despite recommendation by national guidelines. High-quality randomized trials evaluating the impact ...

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Section: Discussionmentioning

confidence: 99%

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Kumar¹,

Shahripour²,

Harrigan

2016

JNS

155

100

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“…Their conclusion was that milrinone administered I.A. was effective and safe in treatment of cerebral vasospasm [2].…”

Section: Discussionmentioning

confidence: 98%

The Risk of Milrinone Use in Severe Neurological Insult and Stunned Myocardium

Wirkowski¹,

Kocztorz²,

Hanna³

et al. 2015

WJCD

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Acute neurological injuries cause catecholamine-induced cardiac damage and can result in or exacerbate preexisting cardiac failure. Milrinone (primacor) has been effective in the treatment of cardiac failure as well as cerebral vasospasm. We would like to present the outcomes of milrinone use in patients with major neurological injuries and preexisting compromised myocardial function. Four patients, age < 60 y/old, three women (two postpartum) and one man, will be presented. Two were diagnosed with a subarachnoid hemorrhage (SAH) coupled with severe vasospasm; one had status epilepticus (SE); and one had cerebral ischemia (CVA) due to carotid artery occlusion. All patients had cardiomyopathy with EF < 35%. All patients were on at least one press or prior to being put on milrinone. Three out of the four patients required an increase in norepinephrine or additional pressors after milrinone was added. All of the patients developed tachycardia, three severe and one mild. In two patients milrinone had to be discontinued due to the persistent hypotension. In our experience, use of milrinone drip in patients with preexisting cardiomyopathy led to hypotension and tachycardia, and brought about the need to increase or add new pressors, which in turn exacerbated catecholamine-induced myocardial injury.

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“…Milrinone seems to be safe and effective to dilate spastic cerebral arteries 18 . Due to its limited duration of action, an intravenous infusion is necessary to obtain a sustained effect.…”

Section: Curative Treatmentmentioning

confidence: 97%

Modern Approach to SAH in Intensive Care Unit (ICU)

Bruder

Velly²,

Codaccioni³

2008

Interv Neuroradiol

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SAH is still a severe pathology carrying a high risk of death or severe neurological morbidity. New diagnostic, monitoring and therapeutic methods are available for the detection and treatment of vasospasm. This includes transcranial Doppler, CT or MRI perfusion scan, protein S100B dosage, cerebral blood flow monitoring at the bedside. Medical treatment of vasospasm relies on increased blood pressure and dobutamine. Emergency balloon angioplasty or arterial vasodilator infusion is mandatory in case of vasospam-induced ischemic deficit. Despite several medical advances in the treatment of subarachnoid haemorrhage (SAH) due to aneurysm rupture, particularly interventional neuroradiology, it remains a potentially devastating illness with a high mortality rate. The most important determinant of outcome is neurologic state on arrival in the hospital, assessed with the World Federation of Neurological Surgeons (WFNS) scale (table 1) 1. Delayed cerebral ischemia due to cerebral vasospasm and medical complications due to SAH have both a major impact on outcome. The cooperative aneurysm study, including 457 patients with SAH, showed that the proportion of deaths from medical complications (23%) was comparable with the proportion of deaths attributed to the direct effects of the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture (2). Thus, the aim of ICU management is to prevent or to limit the consequences of vasospasm and to treat medical complications that can have an adverse effect on the brain.

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Milrinone for the Treatment of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Cited by 148 publications

References 24 publications

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Vasospasm on transcranial Doppler is predictive of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

The Risk of Milrinone Use in Severe Neurological Insult and Stunned Myocardium

Modern Approach to SAH in Intensive Care Unit (ICU)

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