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To the Editor:
We thank Drs. Robert-Edan and Lakhal for their kind words [1] regarding our article on practice guidance for hemodynamic management in the prevention of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage [2]. Although the intent of our article was not to describe mechanisms of action, we agree with the writers that the benefits of milrinone in DCI treatment may involve vasodilation and/or cytoprotective mechanisms, perhaps above and beyond milrinone’s inotropic effect. We also agree with the writers that the mechanisms of DCI are varied and incompletely understood. Vasodilation alone is unlikely to ameliorate DCI, as has been demonstrated in more than one randomized controlled trial [3, 4]. Likewise, the mechanisms by which nimodipine provides neuroprotection after subarachnoid hemorrhage are debated to this day [5]. Large randomized trials with suitable end points will be necessary before we can say with any certainty that milrinone does—or does not—have benefit in the management of DCI, and even then we may not fully understand its mechanisms of action.
Sincerely,
Drs. Deem, Livesay, and Treggiari.
References
Robert-Edan V, Lakhal K. Treating vasospasm with IV milrinone: RELAX (the vessel) or DON’T DO IT! Neurocrit Care. 2023. https://doi.org/10.1007/s12028-023-01789-z.
Deem S, Diringer M, Livesay S, Treggiari MM. Hemodynamic management in the prevention and treatment of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2023. https://doi.org/10.1007/s12028-023-01738-w.
Haley EC Jr, Kassell NF, Torner JC, Truskowski LL, Germanson TP. A randomized trial of two doses of nicardipine in aneurysmal subarachnoid hemorrhage. A report of the cooperative aneurysm study. J Neurosurg. 1994;80:788–96.
Macdonald RL, Higashida RT, Keller E, et al. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol. 2011;10:618–25.
Shah VA, Gonzalez LF, Suarez JI. Therapies for delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2023. https://doi.org/10.1007/s12028-023-01747-9.
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Steven Deem reports no conflicts of interest or disclosures. Sarah Livesay has received consulting fees from Lombardi Hill/Stroke Challenges, has received payment for expert testimony, has received support for attending meetings and/or travel from the Neurocritical Care Society, and has a leadership position in the Neurocritical Care Society. Miriam Treggiari has received grant funding from the National Institutes of Health and the Department of Defense.
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This article is related to the Letter to the editor available at https://link.springer.com/article/10.1007/s12028-023-01789-z. This article is related to the original work available at https://link.springer.com/article/10.1007/s12028-023-01738-w.
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Deem, S., Livesay, S. & Treggiari, M.M. Response to “Treating Vasospasm with IV Milrinone: RELAX (the Vessel) or DON’T DO IT!”. Neurocrit Care 39, 549 (2023). https://doi.org/10.1007/s12028-023-01790-6
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DOI: https://doi.org/10.1007/s12028-023-01790-6