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Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol

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Abstract

Introduction

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.

Methods

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.

Results

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).

Conclusion

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.

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Acknowledgments

The study was partially supported by internal departmental funds from the Department of Anesthesia of the Montreal Neurological Hospital.

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Authors and Affiliations

  1. Department of Anesthesia, Faculty of Medicine McGill University, Montreal Neurological Hospital, Room 548, 3801 University Street, Montreal, QC, H3A 2B4, Canada

    Marcelo Lannes & Mark Angle

  2. Department of Neurology, Faculty of Medicine McGill University, Montreal Neurological Hospital, Montreal, QC, Canada

    Jeanne Teitelbaum & Mauro Cardoso

  3. Department of Radiology, Faculty of Medicine McGill University, Montreal Neurological Hospital, Montreal, QC, Canada

    Maria del Pilar Cortés

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  1. Marcelo Lannes
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Correspondence to Marcelo Lannes.

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Lannes, M., Teitelbaum, J., del Pilar Cortés, M. et al. Milrinone and Homeostasis to Treat Cerebral Vasospasm Associated with Subarachnoid Hemorrhage: The Montreal Neurological Hospital Protocol. Neurocrit Care 16, 354–362 (2012). https://doi.org/10.1007/s12028-012-9701-5

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