Date: 18 Apr 2012
Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol
Rent the article at a discountRent now
* Final gross prices may vary according to local VAT.Get Access
For the treatment of cerebral vasospasm, current therapies have focused on increasing blood flow through blood pressure augmentation, hypervolemia, the use of intra-arterial vasodilators, and angioplasty of proximal cerebral vessels. Through a large case series, we present our experience of treating cerebral vasospasm with a protocol based on maintenance of homeostasis (correction of electrolyte and glucose disturbances, prevention and treatment of hyperthermia, replacement of fluid losses), and the use of intravenous milrinone to improve microcirculation (the Montreal Neurological Hospital protocol). Our objective is to describe the use milrinone in our practice and the neurological outcomes associated with this approach.
Large case series based on the review of all patients diagnosed with delayed ischemic neurologic deficits after aneurysmal subarachnoid hemorrhage between April 1999 and April 2006.
88 patients were followed for a mean time of 44.6 months. An intravenous milrinone infusion was used for a mean of 9.8 days without any significant side effects. No medical complications associated with this protocol were observed. There were five deaths; of the surviving patients, 48.9 % were able to go back to their previous baseline and 75 % had a good functional outcome (modified Rankin scale ≤2).
A protocol using intravenous milrinone, and the maintenance of homeostasis is simple to use and requires less intensive monitoring and resources than the standard triple H therapy. Despite the obvious limitations of this study’s design, we believe that it would be now appropriate to proceed with formal prospective studies of this protocol.
Rinkel GJ, Feigin VL, Algra A, van Gijn J. Circulatory volume expansion therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2004:CD000483.
Tseng MY, Czosnyka M, Richards H, Pickard JD, Kirkpatrick PJ. Effects of acute treatment with pravastatin on cerebral vasospasm, autoregulation, and delayed ischemic deficits after aneurysmal subarachnoid hemorrhage: a phase II randomized placebo-controlled trial. Stroke. 2005;36:1627–32.PubMedCrossRef
Zhang S, Wang L, Liu M, Wu B. Tirilazad for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2010:CD006778.
Nishiguchi M, Ono S, Iseda K, Manabe H, Hishikawa T, Date I. Effect of vasodilation by milrinone, a phosphodiesterase III inhibitor, on vasospastic arteries after a subarachnoid hemorrhage in vitro and in vivo: effectiveness of cisternal injection of milrinone. Neurosurgery. 2010;66:158–64. discussion 164.PubMedCrossRef
Arakawa Y, Kikuta K, Hojo M, Goto Y, Ishii A, Yamagata S. Milrinone for the treatment of cerebral vasospasm after subarachnoid hemorrhage: report of seven cases. Neurosurgery. 2001;48:723–8. (discussion 728–30).PubMed
Lao A, Sharma VK, Katz ML, Alexandrov AV. Diagnostic criteria for transcranial doppler ultrasound. In: McGahan JP, Goldberg BB, eds. Diagnostic ultrasound: logical approach. 2nd ed. New York: Informa Healthcare; 2008. p. 552–554.
Wijdicks EFM. The clinical practice of critical care neurology. Oxford: Oxford University Press; 2003.
Egge A, Waterloo K, Sjøholm H, Solberg T, Ingebrigtsen T, Romner B. Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery. 2001;49:593–605. (discussion 605–6).PubMed
- Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol
Volume 16, Issue 3 , pp 354-362
- Cover Date
- Print ISSN
- Online ISSN
- Humana Press Inc
- Additional Links
- Subarachnoid hemorrhage
- Cerebral vasospasm
- Milrinone lactate
- Phosphodiesterase inhibitors
- Cerebrovascular circulation
- Treatment outcome
- Industry Sectors
- Author Affiliations
- 1. Department of Anesthesia, Faculty of Medicine McGill University, Montreal Neurological Hospital, Room 548, 3801 University Street, Montreal, QC, H3A 2B4, Canada
- 2. Department of Neurology, Faculty of Medicine McGill University, Montreal Neurological Hospital, Montreal, QC, Canada
- 3. Department of Radiology, Faculty of Medicine McGill University, Montreal Neurological Hospital, Montreal, QC, Canada