E.03 Use of intra-arterial milrinone rescue therapy in patients with refractory and super refractory vasospasm after aneurysmal subarachnoid hemorrhage

Abstract

Background: Vasospasm causing delayed ischemic neurologic deficit (DIND) remains a leading cause of devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH). Therapy using intravenous milrinone (IVM) and intra-arterial milrinone (IAM) has been described. We report our results using IAM in patients with refractory and super refractory vasospasm (RV and SRV respectively). Methods: Retrospective single center study of all adult patients treated with IAM between 2006 and 2016 inclusively. IAM was used as part of the Montreal Neurological Hospital Protocol when the patients’ symptoms failed to respond to initial and higher IVM doses. We report their clinical outcomes. Results: IAM was used in 19 patients. The median loading dose was 8 mg and average maintenance dose was 0.78 mcg/kg/min. Angiographic improvement was seen in 15 (79%) and clinical improvement - within the first 48 hours - was seen in all patients. The median mRS was 3 at time of discharge and 1 three months later. Five patients lost follow up. Conclusions: IAM appears to be safe and effective in this small retrospective series of RV and SRV complicating aSAH. Angiographic and clinical improvements were observed. Further prospective studies are warranted to confirm these findings.

The Use of Milrinone in Patients with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Systematic Review

“…Functional neurological status can be ascertained by means of established scales (mRS, GOS) or by detailed follow-up neurological examination (usually at 3 and 6 months), and is usually described as “good” or “bad.” A total of 9 studies including 632 patients reported mRS scores 18 , 20 - 21 , 28 - 33 and GOS scores 14 , 27 in patients with DCI treated with milrinone, with follow-up times that varied from “at discharge” to a mean of 44.6 months. Good outcomes (mRS≤2 or GOS≥4) were seen in 57-82% of patients.…”

“…Measured outcomes and follow-up times were also very diverse: angiographic response, 14 - 21 Neurological exam, 13 , 17 , 22 - 26 Glasgow Outcome scale (GOS), 27 modified Rankin Scale (mRS), 18 , 20 , 21 , 28 - 33 cerebral infarction, 31 Barthel index, 28 and TCD values 34 35 In 7 studies only data on immediate results were available, 14 , 15 , 17 , 19 , 23 , 34 , 35 and in one publication the follow-up time was not specified 24 .…”

Intravenous administration of Milrinone, as an alternative approach to treat vasospasm in subarachnoid hemorrhage: A case report of transcranial Doppler monitoring

“…Recent retrospective series reported that an intra‐arterial milrinone treatment with angiography is safe and effective to reduce refractory VSP after SAH . Important to notice though, that in these studies, patients who did not recover from the coma status were excluded.…”

“…Milrinone is an inhibitor of phosphodiesterase III, with positive inotropic and vasodilatory effects . Although intra‐arterial milrinone contributes to the reduction of VSP, this usually requires concomitant use of angiography . On the other hand, its intravenous use is not well known and further studies are needed to assess this option, supported by bedside monitoring to guarantee the safety and effectiveness of the treatment.…”

“…Recent retrospective series reported that an intra-arterial milrinone treatment with angiography is safe and effective to reduce refractory VSP after SAH. 12,13 Important to notice though, that in these studies, patients who did not recover from the coma status were excluded. Furthermore, evidence about treatment of DCI with milrinone and its use to improve outcomes in patients with SAH, come from studies regarded of very low quality.…”