Introduction: Early treatment of ruptured intracranial aneurysms is the standard of care either with operative microsurgery or endovascular coil embolization. Development of vasospasm occurs across as a significant percentage of patients with ruptured aneurysms. Previous studies estimate approximately 33% of patients present in a delayed fashion with symptomatic vasospasm, attributed primarily to restricted cerebral blood flow and multifocal cerebral infarctions secondary to arterial narrowing. Microsurgical clipping is avoided in patients with vasospasm given need for vessel manipulation and resultant worsening vasospasm. Combined vasospasm treatment using intra-arterial nicardipine with coil embolization of aneurysm may be a safe and effective treatment standard for these patients as documented herein.

Methods: On retrospective analysis, 17 patients of a total 342 presenting with confirmed intracranial aneurysmal rupture at our institution between November 2008 and July 2013 were treated for vasospasm using intra-arterial nicardipine during coil embolization. Variables collected included upon admission included postbleed day, presenting symptoms, Hunt and Hess scores, Fisher grades, aneurysm size, aneurysmal location, and distribution of vasospasm. Such variables were compared with general clinical outcomes across the cohort in addition to those patients presenting similarly in vasospasm who did not receive intra-arterial nicardipine therapy.

Results: Endovascular treatment was performed successfully in all patients with resolution of vasospasm and obliteration of aneurysm. The intra-arterial nicardipine dose administered in these cases ranged from 5 mg-68 mg (mean, 23 mg). 7 patients required repeat vasospasm treatment in a subsequent session. 12 patients made a good recovery by discharge, 2 were deemed moderately disabled, and 3 passed away while over their initial hospital course. There were no immediate procedure-related complications. Comparison of treatment effects by vessel and distribution and pre- and post-treatment were examined in full (Tables 2, 3).

Conclusions: Administration of intra-arterial nicardipine is a generally safe and effective therapy for the treatment vasospasm during coiling of ruptured aneurysms.

Patient Care: The ability to deliver localized nicardipine therapy in a safe and effective fashion in the setting of ruptured intracranial aneurysms presents another option to clinicians in the management of vasospasm as currently one of the leading causes of morbidity and mortality in patients who survive initial insult following aneurysmal subarachnoid hemorrhage.

Learning Objectives: To document initial success demonstrated in the management of moderate to severe cerebrovascular vasospasm secondary to intracranial aneurysmal rupture through localized administration of intra-arterial nicardipine.

References: 1) Macdonald RL, Weir B. Epidemiology. In: Cerebral Vasospasm. San Diego, CA: Academic Press; 2004: 16-18.