Endovascular Management of DCI – Strategies for success
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Transcript of Endovascular Management of DCI – Strategies for success
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
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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)
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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
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Dr Vipul Gupta
Thank you ….