Continuous intracisternal nimodipine administration as rescue therapy for refractory vasospasm in patients with aneurysmal subarachnoid haemorrhage

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PURPOSE: Delayed cerebral ischaemia (DCI) and cerebral vasospasm (CVS) remain major causes of poor outcome in survivors of aneurysmal subarachnoid haemorrhage (aSAH). We aimed to investigate the safety and efficacy of intracisternal administration of nimodipine in patients suffering from symptomatic CVS refractory to treatment with induced hypertension and endovascular vasodilator therapy. METHODS: We performed a single-centre, retrospective, observational study including all patients diagnosed with refractory CVS after aSAH treated at our tertiary centre between January 2018 and December 2021 who received continuous intracisternal nimodipine. For nimodipine administration, a catheter was inserted in the optico-carotid cistern via supraorbital craniotomy. Our primary outcome was functional independence measured by the modified Rankin Scale (mRS) at 6 months. Secondary outcomes included treatment related complications and neurological outcome. RESULTS: We included 15 patients in total. Clinical outcome measured by the mRS at 6 months was good with 93.3% of patients showing mRS ≤ 1 (median mRS 1; range 1-4) Eight patients (53%) developed a new CVS-related neurological deficit during intrathecal nimodipine treatment and additionally received bolus intra-arterial nimodipine. Two patients (13%) developed acute subdural/epidural hematoma postoperatively, which was treated surgically in one patient. In two patients (13%), accidental dislocation of the intrathecal catheter occurred, which warranted re-operation. CONCLUSION: Continuous intracisternal administration of nimodipine may be a viable rescue therapy option for patients with refractory CVS but is associated with an increased risk of treatment related complications.

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