Continuous intra-arterial infusion of nimodipine during embolization of cerebral aneurysms associated with vasospasm

BACKGROUND AND PURPOSE: Despite rigorous efforts, cerebral vasospasm remains an important cause of morbidity and mortality in patients who survive their initial subarachnoid hemorrhage. In cases of intracranial ruptured aneurysm associated with vasospasm, we evaluated the effectiveness of combined embolization of an aneurysm and intra-arterial infusion of nimodipine, which continued during the entire procedure.Materials and METHODS: Ten patients with ruptured aneurysms associated with vasospasm who were treated in a single session were reviewed retrospectively. After initial intra-arterial infusion of nimodipine (1–2 mg within 10–15 minutes), they underwent occlusion of the aneurysm with coils under continuous intra-arterial infusion of nimodipine at a dose of 1 mg per hour.RESULTS: Angiography showed severe proximal vasospasm in 1 patient, proximal and distal in 3 patients, and distal in 3 patients. There was also moderate proximal vasospasm in 4 patients, proximal and distal in 1 patient, and distal in 1 patient. Complete occlusion of the aneurysm was achieved in 5 patients, incomplete occlusion in 3 patients, and a small neck remnant in 2 patients. Final angiograms also demonstrated complete clearance of a proximal spasm in 4 patients, and complete clearance of proximal and distal spasms in another 4 patients. Mean initial dose of nimodipine was 1.375 mg, and mean continuous infusion dose was 1.275 mg (mean total dose, 2.65 mg). No medical complications related to extended infusion of nimodipine occurred.CONCLUSION: In this small series, extended intra-arterial infusion of nimodipine up to the end of the embolization procedure was effective and safe in patients with a ruptured aneurysm and associated vasospasm. This technique seems to increase the security of the procedure as well as force further vasorelaxation when the endovascular route is used to treat both the aneurysm and vasospasm in a single step.

The current optimized approach for patients with a ruptured intracranial aneurysm is to secure the aneurysm early (usually within 3–4 days), either surgically or endovascularly, then apply triple-H therapy alone or in combination with intra-arterial chemical or mechanical angioplasty to overcome vasospasm if it is apparent clinically.¹ In cases of an aneurysm of a high clinical grade or accompanying medical problems that preclude an open surgical procedure, in patients who are candidates for open surgery initially but cannot be operated on later for any reason, and because of other obstacles (ie, geographic distance to referral center) that delay initial intervention, an endovascular interventionalist may encounter an aneurysm along with vasospastic cerebral arteries.Here we describe a simple technique that involves both procedures of aneurysmal embolization and intra-arterial infusion of a vasorelaxing drug in such patients with significant vasospasms.