Correlation of intraventricular nicardipine for refractory vasospasm in aneurysmal subarachnoid hemorrhage with improved neurophysiology on intracranial multimodality monitoring: illustrative case

Figures

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  FIG. 1.. Patient physiology and vasopressor dosage during treatment of vasospasm. Key physiological measures were plotted during the management of cerebral vasospasm. Values for postrupture days 10 to 15 are shown. Measures are time aligned, and 1-minute values are plotted, including cerebral PbtO2 measures (black, goal >20 mm Hg) and blood flow measures (gray, goal >15 mL/100 g/min) obtained with the Licox and QFlow 500 probes, respectively, as well as mean arterial blood pressure as measured continuously with an arterial line (red), SpO2 values measured with a pulse oximeter (blue), and end-tidal CO2 (purple). Infusion dosages of norepinephrine, phenylephrine, and vasopressin are shown in the bottom row (black, red, and blue, respectively). Vertical gray lines denote midnights. The wide gaps in the data reflect the intervals during which interventional cerebral angiography was performed, and the narrow gaps on days 12 and 15 reflect the time when computed tomography was performed. The PbtO2 values increased markedly after the first administration of intrathecal nicardipine despite dropping SpO2 and a decrease in phenylephrine dosage at this time. The perfusion increase noted after…

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  FIG. 2.. Improvement of brain oxygenation and blood flow after administration of intrathecal nicardipine as compared with intraarterial procedures. We performed an AUC analysis to quantitatively compare the effect of intrathecal nicardipine with intraarterial procedures on focal cerebral oxygenation and blood flow as measured with Licox and Hemedex probes, respectively. For this analysis, oxygenation and blood flow values were compared for the 6 hours after the respective interventions. A 2-sample t-test was used to compare PbtO2 values, but because perfusion monitoring was performed only after a single administration of intrathecal nicardipine, the AUC values subsequent to the intraarterial procedures were compared with the single AUC value obtained after the intrathecal nicardipine administration. For this analysis, the five intraarterial procedures performed before the initiation of intrathecal nicardipine were compared with values subsequent to the five intrathecal administrations. Both brain oxygenation and blood flow were greater after intrathecal nicardipine administration than after intraarterial procedures; this difference was significant for PbtO2 values (*p = 0.001).

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  FIG. 3.. Improvement of angiographic vasospasm after administration of intrathecal nicardipine. Anteroposterior cerebral angiograms of the left internal carotid artery for days 13 (left) and 14 (right) after cerebral aneurysm rupture. The severe left anterior cerebral artery and middle cerebral artery vasospasm seen on day 13 improved the day after the first administration of intrathecal nicardipine, corresponding to marked improvement in cerebral blood flow and oxygenation noted with the advanced neuromonitors.