Vipul Gupta discusses strategies for managing delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). Vasospasm, occurring 3-14 days post-bleed, is a major cause of DCI. The document outlines preventive measures including oral nimodipine and hydration. Therapeutic options discussed include HHH therapy, intravenous milrinone, and intra-arterial nimodipine and milrinone. The author's protocol involves early detection using monitoring, imaging, and angiography followed by HHH, IV milrinone, and intra-arterial dilatation if needed. Results show intra-arterial dilatation successfully improved perfusion in all

1. Vipul Gupta
Neurointerventional Surgery
Artemis-Agrim Institute of
Neurosciences
Gurgaon
Endovascular Management of DCI –
Strategies for success

2. SAH…
 Prompt occlusion of the ruptured aneurysm is
standard of care
 After the first phase- patients may deteriorate
secondary to
 hydrocephalus,
 delayed ischemic neurologic deficits (DIND)
 multiple medical complications including
cardiomyopathy and nosocomial infections

3. Vasospasm
 Incidence- angiographic vasospasm 30-70%
 Clinical with risk of stroke or death in 20-30%
 Typically , post bleed day 3-4, peaks at 7-10 days, usually
lasts upto 14-days, can persist for longer as well.
 Cause- amount of hemoglobin in the cisternal space is
the major trigger of the phenomenon that ultimately
causes smooth muscle spasm, narrowing of the arterial
lumen, and impaired blood flow autoregulation.

4. Preventive
 Oral nimodipine
 Hydration
Therapeutic
 HHH therapy
 IV Milrinone
 IA Nimodipine and IA Milrinone
Our Protocol

5.  Early Detection
 Clinical monitoring
 TCD
 CT perfusion – selected cases
 Catheter Angiography
Our Protocol

6. HHH Therapy
 Hypervolemia
 Hemodilution
 Hypertension
Oral nimodipine is started at 60 mg 4hourly dose

7. Intravenous Milrinone infusion
IV milrinone infusion at 0.5mcg/kg/min at the signs of
vasospasm and if required progressive dose increase
to a maximum of 1.5mcg/kg/min
Also can be used intra-arterially

8. Milrinone infusion
• Phosphodiesterase III inhibitor combine vasodilating and
inotropic properties, resulting from the increase in cAMP in
the cytosol of vascular smooth muscle cells and
cardiomyocytes.
• Milrinone is widely used to treat patients with acute heart
failure.
• The combination of potent vasodilatation with
reinforcement of inotropy

9. Milrinone infusion
• Experience of more than 150 patients now at Medanta (overall appx
900 Cases)
• Required IA dilation in only 23 cases after IV Milrinone
• Prior to this 48 IA dilatations were done in 80 cases of vasospasm
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10. 1 ampoule of
milrinone (10 mg)
Dissolve it in
40ml of saline(
total volume 50
ml)
Start at rate of 9ml
/hour and can
increase up to 22
ml/hour
Dose Simplified

11. Endovascular treatment
 Intra-arterial infusion of vasodilators-
(Verapamil, Nimodpine, Nicardapine, Milrinone)
 Transluminal balloon angioplasty

12. Transluminal angioplasty…
 Zubkov et al descibed in 1984
Technique-
 GA
 Dedicated neurovascular balloons (eg hyperglide,
hyperform)
 May be undersized angioplasty balloons
 Vessels- ICA, MCA (M1, M2), ACA (A1),VA, BA, PCA (P1,
P2)
 Specialist, skills, risks, costs, distal vessels

13. Results of angioplasty
Key features
•Early intervention was better
•Can have serious complications
Complications- vessel rupture, dissection, thromboembolism,
reperfusion hemorrhage
Rupture- 0-7%, 1.1%, overall risk- 5%

14. Intra-arterial dilatation…
 I/A Nimodpine, Nicardapine,Verapamil
Nimodipine- 43% angiographic, 72% clinical
 Dilatation at arteriolar level, neuroprotective
effect
Nicardapine-
 Badjatia et al – angio in all, clinical 42%
 Tejada et al angio in all, clinical in 90%

15. Results of chemical
angioplasty…
Key
•Variable results, repeated procedures
•Sometimes clinical results better than radiological
•Complication- BP drop
•No randomized studies

16. Our IAVD approach …
• We do as soon as possible – like “acute stroke”
• HHH – bridging therapy
• Local anesthesia , Anesthesia cover
• Diagnostic catheter
• 3 mg of nimodipine
• Followed by 6-8 mg of Milrinone
• Duration as important as amount
• Followed by HHH and IV milrinone
• High rate of angiographic success (90%)

18. 32-year –old female with ictus 10-days back,
initially Grade II
Deteriorated over last 36-hours to M5, hemiplegic,
aphasic status

21. 6-months follow-up DSA
Patient made almost complete recovery except
for mild weakness in right ankle

22.  54 female
 SAH 5-days
 Grade II

24. Day 6
Day 10

25. Day 13

26.  28 y.o female
 SAH 1 day
 H & H Grade II

27. Day 6 Confused, weak
on right side
CBF CBV MTT

28. Pre-Dilatation Post nimodipine Post Milrinone

29.  60 y.o female
 SAH 2 days
 H & H Grade II

31. Day
5
Post
Nimod
ipine

32. Day
6
Pre-Dilatation Post Nimodipine Post Milrinone

33. Day 7
Continuous intra-arterial dilatation
Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic
Vasospasm After Subarachnoid Hemorrhage
Musahl, Christian; Henkes, Hans; Vajda, Zsolt; Neurosurgery. 68(6):1541-1547, June 2011.

35. Day 11

36. Protocol for vasospasm.
Anand S, Goel G, Gupta V.
J Neurosurg Anesthesiol. 2014 Jul;26(3):263.
Continuous intra-arterial dilatation with nimodipine and
milrinone for refractory cerebral vasospasm.
Anand S, Goel G, Gupta V.
J Neurosurg Anesthesiol. 2014 Jan;26(1):92-3.
330 “Continuous Intra-arterial Dilatation with Combination of
Nimodipine and Milrinone in Severe and Refractory Vasospasm”
Goel G, Gupta V , Anand S, Chinchure S, Gupta A, Jha AN
12th Congress of the WFITN & ICS 2013.

37. Results
Results
• IAVD was successful in all in improving perfusion except for
one patient
• Continuous dilatation in 6 patients, good outcome in 4.
• except for 5 patients rest all had a good outcome (mRS0-2)
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38. Day 9

40.  Act early
 IV milrinone is safe, feasible
 Intra-arterial dilatation with
nimodipine and/or milrinone is an
effective method
 Lower dose over longer period is
effective
 Early dilatation influence outcome
 May need to do multiple dilatations
 Intensive monitoring and hydration
help
Conclusions

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42. Thank you ….