A349 Selective intra-arterial lidocaine administration into the middle meningeal artery for headache and nuchal rigidity after aneurysmal subarachnoid haemorrhage: a single-centre experience

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Background/Introduction Headache after aneurysmal subarachnoid haemorrhage is often severe and difficult to control. Opioids may complicate neurological assessment. Selective lidocaine delivery into the middle meningeal artery (MMA) may modulate meningeal nociception, but clinical evidence is limited. Objective/Purpose To evaluate headache intensity, nuchal rigidity, angiographic response and procedural safety after selective intra-arterial lidocaine following endovascular aneurysm treatment. Methods/Case Description We retrospectively analysed 74 consecutive patients with aneurysmal subarachnoid haemorrhage treated at one centre between September 2024 and March 2026. After endovascular aneurysm securing, 5–50 mg lidocaine diluted to 10 mL was injected into each treated MMA. Headache was assessed on an 11-point numerical rating scale at admission, five hours after treatment, daily to day 10 and at three months. Nuchal rigidity and immediate angiographic narrowing were recorded. Two patients without reliable serial pain assessment were excluded from efficacy analysis. Results/Findings Seventy-four patients and 131 arteries comprised the safety cohort; 72 patients comprised the efficacy cohort. Median headache intensity decreased from 8 at admission to 1 at five hours (p<0.001). A reduction of at least 2 points occurred in 65/72 patients (90.3%); 40/72 (55.6%) achieved a score of 0–1. Median intensity remained 1 through day 10, and 57/72 patients (79.2%) reported no headache at three months. Moderate or severe nuchal rigidity was present in 50/72 patients at admission; by day 10, rigidity was absent in 42 and mild in 30. Immediate angiographic narrowing occurred in 130/131 arteries. No complication was directly attributed to catheterisation or lidocaine administration. Discussion/Conclusions/Learning Points Selective intra-arterial administration of lidocaine into the MMA was technically feasible and was associated with early reduction in headache intensity and gradual improvement in nuchal rigidity. The consistent immediate angiographic response supports a local pharmacological effect. However, given the uncontrolled study design, these findings should be interpreted with caution and require confirmation in prospective controlled studies.

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