endovascular management of dci – strategies for success
TRANSCRIPT
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Vipul GuptaNeurointerventional Surgery
Artemis-Agrim Institute of
Neurosciences
Gurgaon
Endovascular Management of DCI –
Strategies for success
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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
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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.
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Preventive
Oral nimodipine
Hydration
Therapeutic
HHH therapy
IV Milrinone
IA Nimodipine and IA Milrinone
Continuous Intra-arterial dilatations
Our Protocol
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Early Detection
Clinical monitoring
TCD
CT perfusion – selected cases
Catheter Angiography
Our Protocol
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HHH Therapy
Hypervolemia
Hemodilution
Hypertension
Oral nimodipine is started at 60 mg 4hourly dose
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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
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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
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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
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Endovascular treatment
Intra-arterial infusion of vasodilators-
(Verapamil, Nimodpine, Nicardapine, Milrinone)
Transluminal balloon angioplasty
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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
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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%
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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%
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Results of chemical angioplasty…
Key•Variable results, repeated procedures
•Sometimes clinical results better than radiological
•Complication- BP drop
•No randomized studies
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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%)
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32-year –old female with ictus 10-days back,
initially Grade II
Deteriorated over last 36-hours to M5, hemiplegic,
aphasic status
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6-months follow-up DSA
Patient made almost complete recovery except
for mild weakness in right ankle
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54 female
SAH 5-days
Grade II
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Day 6
Day 10
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Day 13
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28 y.o female
SAH 1 day
H & H Grade II
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Day 6 Confused, weak
on right side
CBF CBV MTT
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Pre-Dilatation Post nimodipine Post Milrinone
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60 y.o female
SAH 2 days
H & H Grade II
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Day
5
Post
Nimod
ipine
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Day
6
Pre-Dilatation Post Nimodipine Post Milrinone
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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.
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Day 11
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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.
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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
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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
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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
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Thank you ….