Safety and efficacy of intrathecal nicardipine for aneurysmal subarachnoid hemorrhage induced vasospasm

Background: Cerebral vasospasm (CV) is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. Objective: To report our institutional experience with intrathecal (IT) nicardipine for treatment of moderate to severe CV. Methods: A retrospective study was performed for all patients treated with intrathecal nicardipine from October 2014-May 2017. The primary goal was to evaluate the safety of IT nicardipine to treat subarachnoid induced CV. Results. 48 patients with aSAH were treated with IT nicardipine for moderate or severe CV. The average age of patients was 49.6 years (range 14-77 years) with mean Hunt Hess of 3.2 and mean Fisher scores of 3.1. Patients were treated with different dosing regiments ranging from 2 mg q12 to 4 mg q8hr. The average total dose was 35.1 mg (range 6 to 112 mg). The average initiation of treatment was post bleed day 6 (range day 2-15) and length of treatment was 5.9 days (range 1-15 days.) 10/48 (20.8%) patients underwent TBA with only 4/48 (8.3%) treated after initiation of IT nicardipine. Three patients (6.3%) developed meningitis/ventriculitis. Three (6.3%) patients required ventriculoperitoneal shunt. Favorable outcome (Glasgow Outcome Scale 4 or 5) was achieved in 56.3% of patients. Conclusions: The use of intrathecal nicardipine should be considered a safe option in the treatment of moderate to severe cerebral vasospasm. The use of intrathecal nicardipine has resulted in a near discontinuation of balloon angioplasty in our institution. Randomized trials to identify the optimal dosing, timing, and length of treatment is warranted.