Aggressive management of vasospasm with direct intra-arterial nimodipine therapy

Background: The conventional medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is associated with uncertainty of outcome and complications. Aims and Objectives: To examine the effect of direct intra-arterial nimodipine therapy on outcome in patients with delayed cerebral ischemia (DCI). Settings and Design: The retrospective observational study was conducted at a single neurosurgical unit and interventional neuroradiolgy suite of a center managing SAH. Materials and Methods: Data analysis of SAH managed surgically during the period from January 2014 through October 2015 was performed. Any decline in the neurological status on clinical examination, such as consciousness, motor and speech deficits, without other identifiable causes such as hydrocephalus, hyponatremia, seizure, intracranial hematoma, or infection, was used to define the presence of DCI. Patients with suspected DCI underwent computed tomography (CT) scan of the head followed by angiography. When vasospasm was detected in the absence of any major arterial territory infarct, the patients were managed with intra-arterial nimodipine therapy. The outcome at discharge was assessed. Statistical Analysis: Mid-P exact, two-tailed P value was used for categorical variables. Results: A total of 106 patients underwent surgical clipping of an aneurysm following SAH. DCI was diagnosed in 26 (24.5%) patients. Twenty three (88.5%) patients underwent intra-arterial nimodipine therapy. Angiographic response was seen in 22 (95.7%) patients and clinical response in 20 (87%) patients. At discharge, 19 patients (73.1%) with vasospasm had a favorable outcome. There was no significant difference in the outcome of patients with or without vasospasm. Conclusions: Aggressive management with intra-arterial nimodipine therapy is effective in preventing disability caused by DCI.