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Research ArticleNeurointervention

Intra-Arterial Nimodipine for Severe Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: Influence on Clinical Course and Cerebral Perfusion

D. Hänggi, B. Turowski, K. Beseoglu, M. Yong and H.J. Steiger
American Journal of Neuroradiology June 2008, 29 (6) 1053-1060; DOI: https://doi.org/10.3174/ajnr.A1005
D. Hänggi
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B. Turowski
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K. Beseoglu
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M. Yong
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H.J. Steiger
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    Fig 1.

    The box-plot profiles of blood-flow velocity measured with TCD, from day 0 (preintervention) to the 7 days postintervention. The plus represents the sample mean value. The asterisk indicates P < .05 for the change from baseline.

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    Fig 2.

    The box-plot profiles of perfusion parameters measured with perfusion CT: MTT (A), Tmax (B), cerebral blood flow (C), and cerebral blood volume (D), by time 0 (preintervention), 1 (first day after intervention), 2 (2–5 days postintervention), to 3 (5–9 days postintervention). The plus signs are the sample mean values. The asterisk indicates P < .05 for the change from baseline.

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    Fig 3.

    Correlation between the first day change of flow velocity measured with TCD and the first day change of perfusion parameters measured with perfusion CT: MTT (A), Tmax (B), cerebral blood flow (C), and cerebral blood volume (D). Data are presented with correlation coefficients (r) and univariate linear regression with 95% confidence intervals.

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    Fig 4.

    Illustrative case 12. A, Baseline angiogram on day 6 documents severe vasospasm in the left M1 and M2 segments (arrows). B, DSA obtained 10 minutes after the injection of 1.6-mg nimodipine reveals reduction of the vasospasm (arrows). C, PCT approximately 24 hours after IAN demonstrates a reduction of MTT and Tmax. D, No ischemic lesions are documented on the CT scan obtained at the time of discharge.

Tables

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    Table 1:

    Characteristics of patients with cerebral vasospasm who were treated with IAN

    Patient No.Age (yr)/SexWFNS GradeFisher GradeAneurysm LocationTreatmentVasospasm Confirmed by DSA*
    167/FIVIVPICA leftClipping15
    247/MIIVMCA leftClipping11
    347/FIIIIVMCA leftClipping8
    459/MIIIIVPericallosal leftClipping6, 9
    549/FIIIIBACoiling7
    665/FIVIVAcomAClipping16
    748/MIIIIVMCA rightClipping8
    854/MIIIIVICA leftCoiling11
    936/FIIIIVAcomAClipping9
    1046/FIVIVBACoiling5, 6
    1146/FIIIAcomACoiling6
    1233/MIIIIMCA leftClipping7
    1337/MIIIAcomAClipping3
    1449/FIIIIAcomACoiling6
    1573/FIVIVPcomA leftClipping4
    1658/MIIIIIPICA rightCoiling10
    1740/MIIIAcomACoiling5, 6
    1827/MIVIVICA leftClipping5, 13
    1948/FIVIVICA rightClipping10, 11
    2058/MIIIMCA rightClipping7, 11
    2170/FIIIIIMCA leftClipping8, 9
    2255/FIVIVPcomA rightCoiling8
    2336/MIIVICA rightCoiling10
    2465/MIIIIAcomAClipping5, 7, 8, 11
    2549/FIVIVAcomACoiling0, 3, 10
    2642/MIIIIVICA leftCoiling7, 11, 12, 14, 18
    • Note:—ICA indicates internal carotid artery; AcomA, anterior communicating artery; MCA, middle cerebral artery; PcomA, posterior communicating artery; BA, basilar artery; PICA, posterior inferior cerebellar artery; WFNS, World Federation of Neurological Surgeons; DSA, digital subtraction angiography.

    • * In days after the index SAH.

    • View popup
    Table 2:

    Individual treatment schedules and postinterventional angiographic results

    Patient No.Distribution of VasospasmIANIAN Dosage per Session (mg)Continuous IANFormer PTADirect DSA Result
    1ACA/MCA bICA b3.2––+
    2ACA/MCA lICA l1.64 mg/h, 2 hours–(+)
    3MCA lICA l0.8––++
    41) ACA b1) ICA b1) 3.21) −1) −1) ++
    2) ACA b2) ICA b2) 3.22) –2) –2) +
    5MCA bICA b3.2––++
    6ACA/MCA lICA l1.6––++
    7MCA rICA r1.6–Yes++
    8MCA lICA l1.6––(+)
    9MCA lICA l0.8–Yes++
    101) ICA l1) ICA l1) 3.21) −1) −1) +
    2) ICA l2) ICA l2) 3.22) –2) –2) +
    11ACA lICA l1.6–Yes++
    12MCA lICA l1.6––++
    13ACA rICA r1.6––(+)
    14ACA bICA b3.2––+
    15ICA lICA l1.6––++
    16MCA lICA l1.6–(+)
    PCA lVA l1.64 mg/h, 2 hours
    171) ICA b1) ICA b1) 3.21) −1) −1) ++
    2) ICA b2) ICA b2) 3.22) 4 mg/h, 2 hours2) –2) (+)
    181) ICA left1) ICA left1) 1.61) −1) Yes1) +
    2) ICA right2) ICA right2) 1.62) –2) Yes2) +
    • Note:—ACA, anterior cerebral artery; MCA, middle cerebral artery; ICA, internal carotid artery; PCA, posterior cerebral artery; VA, vertebral artery; l, left-sided; r, right-sided; b, bilateral; DSA, digital subtraction angiography; PTA, balloon angioplasty; (+), minor changes; +, moderate changes; ++, major changes.

    • View popup
    Table 3:

    Change of PCT parameters between immediately before and the day after the IAN intervention*

    Preintervention1 Day PostinterventionP†
    MTT3.27 (2.99–3.84)2.72 (2.24–3.38).17
    Tmax1.66 (1.43–2.29)1.55 (1.12–1.94).03
    CBF13.67 (10.86–15.45)13.90 (9.52–25.96).15
    CBV4.0 (3.51–5.87)3.74 (2.97–5.59).52
    • Note:—CBF indicates cerebral blood flow; CBV, cerebral blood volume; MTT, mean transit time; Tmax, selective time to peak of brain parenchyma.

    • * Data are presented as medians (interquartile range).

    • † With the signed rank test for paired samples.

    • View popup
    Table 4:

    Outcome of patients

    Patient No.Posttreatment Ischemic Lesions (CT)mRS at Discharge*mRS at 3-Month Follow-Up*Adverse Effects
    1Minor54None
    2Minor54Hypotension
    3Minor52Hypotension
    4Minor6–None
    5No00None
    6No21None
    7Minor4–Hypotension
    8No00Hypotension
    9No21None
    10Minor11None
    11Minor00None
    12No00None
    13No00Hypotension
    14No00None
    15Major6–Hypotension
    16Minor1–None
    17Minor00None
    18Minor55None
    • Note:—mRS, indicates modified Rankin Scale.

    • * Scores of 0–2 indicate good outcome; 3–4, moderate outcome; 5–6, poor outcome.

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American Journal of Neuroradiology: 29 (6)
American Journal of Neuroradiology
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June 2008
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D. Hänggi, B. Turowski, K. Beseoglu, M. Yong, H.J. Steiger
Intra-Arterial Nimodipine for Severe Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: Influence on Clinical Course and Cerebral Perfusion
American Journal of Neuroradiology Jun 2008, 29 (6) 1053-1060; DOI: 10.3174/ajnr.A1005

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Intra-Arterial Nimodipine for Severe Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: Influence on Clinical Course and Cerebral Perfusion
D. Hänggi, B. Turowski, K. Beseoglu, M. Yong, H.J. Steiger
American Journal of Neuroradiology Jun 2008, 29 (6) 1053-1060; DOI: 10.3174/ajnr.A1005
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