Skip to main content

The Effect of Intraventricular Administration of Nicardipine on Mean Cerebral Blood Flow Velocity Measured by Transcranial Doppler in the Treatment of Vasospasm Following Aneurysmal Subarachnoid Hemorrhage

Neurocritical Care volume 12, pages 159–164 (2010)Cite this article

Abstract

Background

Cerebral arterial vasospasm and delayed ischemic neurological deficits are significant contributors to morbidity and mortality following aneurysmal subarachnoid hemorrhage. Additional treatment modalities are needed. Intraventricular nicardipine has been suggested as a potential therapy for the treatment of cerebral vasospasm. It is an appealing option for multiple reasons: many of these patients already have ventricular drains in place, it can be safely administered at the bedside, and can be used in patients for whom conventional therapies are either not effective or not tolerated.

Methods

Retrospective case series of all patients who received intraventricular nicardipine for the treatment of cerebral vasospasm from January 2006 to June 2007 at a university tertiary care hospital.

Results

Sixty-four patients received intraventricular nicardipine during the study period. Forty-two patients met inclusion criteria. Intraventricular nicardipine administration was associated with a reduction of the mean cerebral blood flow velocity of 26.3 cm/s in the middle cerebral artery and 7.4 cm/s in the anterior cerebral artery. This reduction was maintained over 24 h with continued administration.

Conclusions

Intraventricular nicardipine was associated with a significant and sustained reduction in mean cerebral blood flow velocity as measured by transcranial Doppler when used in the treatment of suspected cerebral vasospasm following aneurysmal subarachnoid hemorrhage. We do not find significant safety concerns related to elevations of intracranial pressure or ventricular catheter related infections. Further prospective studies are warranted to better determine the efficacy and safety of this therapy.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. Solenski N, Haley E, Kassell N, et al. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study.Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med. 1995;23:1007–17.

    Article  CAS  PubMed  Google Scholar 

  2. Kassell N, Torner J, Haley E, Jane J, Adams H, Kongable G. The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: Overall management results. J Neurosurg. 1990;73:18–36.

    Article  CAS  PubMed  Google Scholar 

  3. Zabramski J, Spetzler R, Bonstelle C. Chronic cerebral vasospasm: effect of calcium antagonists. Neurosurgery. 1986;18:129–35.

    CAS  PubMed  Article  Google Scholar 

  4. Meyer F. Calcium antagonists and vasospasm. Neurosurg Clin N Am. 1990;1:367–76.

    CAS  PubMed  Google Scholar 

  5. Dorhout Mees S, Rinkel G, Feigin V, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane database of systematic reviews 2007.

  6. Badjatia N, Topcuoglu M, Pryor J, et al. Preliminary experience with intra-arterial nicardipine as a treatment for cerebral vasospasm. AJNR Am J Neuroradiol. 2004;25:819–26.

    PubMed  Google Scholar 

  7. Toyota A, Nishizawa Y. Cerebral vasospasm after subarachnoid hemorrhage, and inhibitory effect of nicardipine investigated by means of TCD ultrasonography. No Shinkei Geka (Neurol Surg). 1991;19:1143–50.

    CAS  Google Scholar 

  8. Shibuya M, Suzuki Y, Enomoto H, Okada T, Ogura K, Sugita K. Effects of prophylactic intrathecal administrations of nicardipine on vasospasm in patients with severe aneurysmal subarachnoid haemorrhage. Acta Neurochir. 1994;131:19–25.

    Article  CAS  Google Scholar 

  9. Suzuki M, Doi M, Otawara Y, Ogasawara K, Ogawa A. Intrathecal administration of nicardipine hydrochloride to prevent vasospasm in patients with subarachnoid hemorrhage. Neurosurg Rev. 2001;24:180–4.

    Article  CAS  PubMed  Google Scholar 

  10. Goodson K, Lapointe M, Monroe T, Chalela J. Intraventricular nicardipine for refractory cerebral vasospasm after subarachnoid hemorrhage. Neurocrit Care. 2008;8:247–52.

    Article  CAS  PubMed  Google Scholar 

  11. Ehtisham A, Taylor S, Bayless L, Samuels O, Klein M, Janzen J. Use of intrathecal nicardipine for aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm. South Med J. 2009;102:150–3.

    PubMed  Google Scholar 

  12. Kasuya H, Onda H, Takeshita M, Okada Y, Hori T. Efficacy and safety of nicardipine prolonged-release implants for preventing vasospasm in humans. Stroke. 2002;33:1011–5.

    Article  CAS  PubMed  Google Scholar 

  13. Kasuya H, Onda H, Sasahara A, Takeshita M, Hori T. Application of nicardipine prolonged-release implants: analysis of 97 consecutive patients with acute subarachnoid hemorrhage. Neurosurgery. 2005;56:895–902.

    PubMed  Google Scholar 

  14. Lozier AP, Sciacca RR, Romagnoli MF, Connolly ES. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2002;51:170–81.

    Article  PubMed  Google Scholar 

  15. Bederson JB, Connolly ES, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrahge. a statement for healthcare professionals from a special Writing Group of the Stroke Council, American Heart Association. Stroke. 2009;40:994–1025.

    Article  PubMed  Google Scholar 

  16. Treggiari-Venzi M, Suter P, Romand J. Review of medical prevention of vasospasm after aneurysmal subarachnoid hemorrhage: a problem of neurointensive care. Neurosurgery. 2001;48:49–61.

    Article  Google Scholar 

  17. Liu-Deryke X, Rhoney D. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage: an overview of pharmacologic management. Pharmacotherapy. 2006;26:182–203.

    Article  CAS  PubMed  Google Scholar 

  18. Macdonald R, Pluta R, Zhang J. Cerebral vasospasm after subarachnoid hemorrhage: the emerging revolution. Nat Clin Pract Neurol. 2007;3:256–63.

    Article  CAS  PubMed  Google Scholar 

  19. Haley E, Kassell N, Torner J. A randomized controlled trial of high-dose intravenous nicardipine in aSAH. A report of the Cooperative Aneurysm Study. J Neurosurg. 1993;78:537–47.

    Article  PubMed  Google Scholar 

  20. Haley E, Kassell N, Torner J. A randomized trial of nicardipine in subarachnoid hemorrhage: angiographic and TCD ultrasound results. A report of the Cooperative Aneurysm Study. J Neurosurg. 1993;78:548–53.

    Article  PubMed  Google Scholar 

  21. Weyer G, Nolan C, Macdonald R. Evidence-based cerebral vasospasm management. Neurosurg Focus. 2006;21:1161–70.

    Article  Google Scholar 

  22. Voldby B, Petersen O, Buhl M, Jakobsen P, Ostergaard R. Reversal of cerebral arterial spasm by intrathecal administration of a calcium antagonist (nimodipine). Acta Neurochir. 1984;70:243–54.

    Article  CAS  Google Scholar 

  23. Gioia A, White R, Bakhtian B, Robertson J. Evaluation of the efficacy of intrathecal nimodipine in canine models of chronic cerebral vasospasm. J Neurosurg. 1985;62:721–8.

    Article  CAS  PubMed  Google Scholar 

  24. Kawashima A, Kasuya H, Shiokawa K, Miyajima M, Izawa M, Takakura K. Efficacy of nicardipine prolonged-release pellet on cerebral vasospasm in dogs. No Shinkei Geka (Neurol Surg). 1998;26:37–43.

    CAS  Google Scholar 

  25. Eddleman CS, Hurley MC, Naidech AM, Batjer HH, Bendok BR. Endovascular options in the treatment of delayed ischemic neurological deficits due to cerebral vasospasm. Neurosurg Focus. 2009;26:E6.

    Article  PubMed  Google Scholar 

  26. Komotar RJ, Zacharia BE, Otten ML, Mocco J, Lavine SD. Controversies in the endovascular management of cerebral vasospasm after intracranial aneurysm rupture and future directions for therapeutic approaches. Neurosurgery. 2008;62:897–905.

    Article  PubMed  Google Scholar 

  27. McGirt MJ, Blessing RP, Goldstein LB. Transcranial Doppler monitoring and clinical decision-making after subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 2003;12:88–92.

    Article  PubMed  Google Scholar 

  28. Suarez JI, Qureshi AI, Yahia AB, et al. Symptomatic vasospasm diagnosis after subarachnoid hemorrhage: evaluation of TCD ultrasound and cerebral angiography as related to compromised vascular distribution. Crit Care Med. 2002;30:1348–55.

    Article  PubMed  Google Scholar 

  29. Rigamonti A, Ackery A, Baker AJ. TCD monitoring in subarachnoid hemorrhage: a critical tool in critical care. Can J Anaesth. 2008;55:112–23.

    Article  PubMed  Google Scholar 

  30. Lysakowski C, Walder B, Costanza MC, Tramèr MR. TCD versus angiography in patients with vasospasm due to a ruptured cerebral aneurysm: a systematic review. Stroke. 2001;32:2292–8.

    Article  CAS  PubMed  Google Scholar 

  31. Grosset DG, Straiton J, du Trevou M, Bullock R. Prediction of symptomatic vasospasm after subarachnoid hemorrhage by rapidly increasing TCD velocity and cerebral blood flow changes. Stroke. 1992;23:674–9.

    CAS  PubMed  Google Scholar 

  32. Hurst RW, Schnee C, Raps EC, Farber R, Flamm ES. Role of TCD in neuroradiological treatment of intracranial vasospasm. Stroke. 1993;24:299–303.

    CAS  PubMed  Google Scholar 

  33. Elliott JP, Newell DW, Lam DJ, et al. Comparison of balloon angioplasty and papaverine infusion for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage. J Neurosurg. 1998;88:277–84.

    Article  CAS  PubMed  Google Scholar 

  34. Mayhall CG, Archer NH, Lamb VA, et al. Ventriculostomy-related infections. A prospective epidemiologic study. N Engl J Med. 1984;310:553–9.

    CAS  PubMed  Google Scholar 

  35. Lo CH, Spelman D, Bailey M, Cooper DJ, Rosenfeld JV, Brecknell JE. External ventricular drain infections are independent of drain duration: an argument against elective revision. J Neurosurg. 2007;106:378–83.

    Article  PubMed  Google Scholar 

  36. Frontera JA, Fernandez A, Schmidt JM, et al. Impact of nosocomial infectious complications after subarachnoid hemorrhage. Neurosurgery. 2008;62:80–7.

    Article  PubMed  Google Scholar 

  37. Korinek A, Reina M, Boch A, Rivera A, De Bels D, Puybasset L. Prevention of external ventricular drain related ventriculitis. Acta Neurochir. 2005;147:39–46.

    Article  Google Scholar 

  38. Fujiwara K, Mikawa S, Ebina T. Continuous intrathecal administration of nicardipine using a portable infusion pump system for management of vasospasm after subarachnoid hemorrhage. No Shinkei Geka (Neurol Surg). 2001;29:23–30.

    CAS  Google Scholar 

Download references

Author information

Affiliations

  1. Emory University School of Medicine, Atlanta, GA, USA

    Adam Webb, Jennifer Kolenda, Kathleen Martin, Wendy Wright & Owen Samuels

Authors
  1. Adam Webb
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jennifer Kolenda
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kathleen Martin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wendy Wright
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Owen Samuels
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Adam Webb.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Webb, A., Kolenda, J., Martin, K. et al. The Effect of Intraventricular Administration of Nicardipine on Mean Cerebral Blood Flow Velocity Measured by Transcranial Doppler in the Treatment of Vasospasm Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 12, 159–164 (2010). https://doi.org/10.1007/s12028-009-9307-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-009-9307-8

Keywords

  • Nicardipine
  • Intraventricular administration
  • Vasospasm
  • Subarachnoid hemorrhage
  • Transcranial Doppler