Vipul GuptaNeurointerventional Surgery

Artemis-Agrim Institute of

Neurosciences

Gurgaon

Endovascular Management of DCI –

Strategies for success

SAH…

Prompt occlusion of the ruptured aneurysm is standard of care

After the first phase- patients may deteriorate secondary to

hydrocephalus,

delayed ischemic neurologic deficits (DIND)

multiple medical complications including cardiomyopathy and nosocomial infections

Vasospasm

Incidence- angiographic vasospasm 30-70%

Clinical with risk of stroke or death in 20-30%

Typically , post bleed day 3-4, peaks at 7-10 days, usually lasts upto 14-days, can persist for longer as well.

Cause- amount of hemoglobin in the cisternal space is the major trigger of the phenomenon that ultimately causes smooth muscle spasm, narrowing of the arterial lumen, and impaired blood flow autoregulation.

Preventive

Oral nimodipine

Hydration

Therapeutic

HHH therapy

IV Milrinone

IA Nimodipine and IA Milrinone

Continuous Intra-arterial dilatations

Our Protocol

Early Detection

Clinical monitoring

TCD

CT perfusion – selected cases

Catheter Angiography

Our Protocol

HHH Therapy

Hypervolemia

Hemodilution

Hypertension

Oral nimodipine is started at 60 mg 4hourly dose

Intravenous Milrinone infusion

IV milrinone infusion at 0.5mcg/kg/min at the signs of

vasospasm and if required progressive dose increase

to a maximum of 1.5mcg/kg/min

Also can be used intra-arterially

Milrinone infusion

• Phosphodiesterase III inhibitor combine vasodilating and

inotropic properties, resulting from the increase in cAMP in

the cytosol of vascular smooth muscle cells and

cardiomyocytes.

• Milrinone is widely used to treat patients with acute heart

failure.

• The combination of potent vasodilatation with

reinforcement of inotropy

Milrinone infusion

• Experience of more than 150 patients now at Medanta (overall appx

900 Cases)

• Required IA dilation in only 23 cases after IV Milrinone

• Prior to this 48 IA dilatations were done in 80 cases of vasospasm

0

20

40

60

80

100

120

140

160

180

200

Category1

Category2

Column2

Column1

1 ampoule of milrinone (10 mg)

Dissolve it in 40ml of saline( total volume 50

ml)

Start at rate of 9ml /hour and can

increase up to 22 ml/hour

Dose Simplified

Endovascular treatment

Intra-arterial infusion of vasodilators-

(Verapamil, Nimodpine, Nicardapine, Milrinone)

Transluminal balloon angioplasty

Transluminal angioplasty…

Zubkov et al descibed in 1984

Technique-

GA

Dedicated neurovascular balloons (eg hyperglide, hyperform)

May be undersized angioplasty balloons

Vessels- ICA, MCA (M1, M2), ACA (A1), VA, BA, PCA (P1, P2)

Specialist, skills, risks, costs, distal vessels

Results of angioplasty

Key features•Early intervention was better

•Can have serious complications

Complications- vessel rupture, dissection, thromboembolism,

reperfusion hemorrhage

Rupture- 0-7%, 1.1%, overall risk- 5%

Intra-arterial dilatation…

I/A Nimodpine, Nicardapine, Verapamil

Nimodipine- 43% angiographic, 72% clinical

Dilatation at arteriolar level, neuroprotectiveeffect

Nicardapine-

Badjatia et al – angio in all, clinical 42%

Tejada et al angio in all, clinical in 90%

Results of chemical angioplasty…

Key•Variable results, repeated procedures

•Sometimes clinical results better than radiological

•Complication- BP drop

•No randomized studies

Our IAVD approach …

• We do as soon as possible – like “acute stroke”

• HHH – bridging therapy

• Local anesthesia , Anesthesia cover

• Diagnostic catheter

• 3 mg of nimodipine

• Followed by 6-8 mg of Milrinone

• Duration as important as amount

• Followed by HHH and IV milrinone

• High rate of angiographic success (90%)

32-year –old female with ictus 10-days back,

initially Grade II

Deteriorated over last 36-hours to M5, hemiplegic,

aphasic status

6-months follow-up DSA

Patient made almost complete recovery except

for mild weakness in right ankle

54 female

SAH 5-days

Grade II

Day 6

Day 10

Day 13

28 y.o female

SAH 1 day

H & H Grade II

Day 6 Confused, weak

on right side

CBF CBV MTT

Pre-Dilatation Post nimodipine Post Milrinone

60 y.o female

SAH 2 days

H & H Grade II

Day

5

Post

Nimod

ipine

Day

6

Pre-Dilatation Post Nimodipine Post Milrinone

Day 7

Continuous intra-arterial dilatation

Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic

Vasospasm After Subarachnoid Hemorrhage

Musahl, Christian; Henkes, Hans; Vajda, Zsolt; Neurosurgery. 68(6):1541-1547, June 2011.

Day 11

Protocol for vasospasm.Anand S, Goel G, Gupta V.

J Neurosurg Anesthesiol. 2014 Jul;26(3):263.

Continuous intra-arterial dilatation with nimodipine and

milrinone for refractory cerebral vasospasm.Anand S, Goel G, Gupta V.

J Neurosurg Anesthesiol. 2014 Jan;26(1):92-3.

330 “Continuous Intra-arterial Dilatation with Combination of

Nimodipine and Milrinone in Severe and Refractory Vasospasm”Goel G, Gupta V , Anand S, Chinchure S, Gupta A, Jha AN

12th Congress of the WFITN & ICS 2013.

Results

Results

• IAVD was successful in all in improving perfusion except for

one patient

• Continuous dilatation in 6 patients, good outcome in 4.

• except for 5 patients rest all had a good outcome (mRS0-2)

0

5

10

15

20

25

30

35

40

Column1

single

two

three

four

continous

Day 9

Act early

IV milrinone is safe, feasible

Intra-arterial dilatation with nimodipine and/or milrinone is an effective method

Lower dose over longer period is effective

Early dilatation influence outcome

May need to do multiple dilatations

Intensive monitoring and hydration help

Conclusions

For more information on:

STROKE & NEUROVASCULAR INTERVENTIONS:

URL:www.sanif.co.in

Facebook:https://www.facebook.com/strokeawarenessindiahttps://www.facebook.com/vipul.gupta.35175

Twitterhttps://twitter.com/drvipulgupta25

LinkedINhttps://in.linkedin.com/pub/dr-vipul-gupta/51/8a1/25a

YouTubeChannel: Stroke & Neurovascular Interventionswww.youtube.com/c/StrokeNeurovascularInterventionsfoundation

Dr Vipul Gupta

Thank you ….