title: Repeated combined endovascular therapy with milrinone and nimodipine for the treatment of severe vasospasm: preliminary results.
abstract: BACKGROUND
  Delayed vasospasm (VSP) following aneurysmal subarachnoid hemorrhage (aSAH) remains a major source of morbidity. Milrinone was recently suggested as an invasive VSP treatment option. It is a phosphodiesterase III inhibitor with vasodilating and additional positive inotrope and anti-inflammatory effects.
  
  
  METHODS
  In this preliminary series, we included patients with severe VSP and unsuccessful maximum conservative therapy. Inclusion criteria were (1) transcranial Doppler (TCD) mean >180 cm/s; (2) increase of >50 % of TCD mean values within 6 h to values >150 cm/s; and/or (3) neurological deterioration (after exclusion of hemorrhage, hydrocephalus, and other systemic reasons). Patients received endovascular therapy with nimodipine 2 mg followed by milrinone 4-8 mg. Reinterventions were indicated aggressively in cases of persistent neurological deficits or persistent high mean TCD >180 cm/s.
  
  
  RESULTS
  Of 121 consecutive aSAH patients, 16 (13.2 %) received endovascular VSP therapy. Of these, 11 patients (68.5 %) received ≥ 3 interventions (median 4; maximum 9); 14 (87.5 %) showed postinterventional angiographic improvement of vessel diameters; and 11 (68.5 %) showed improvement of their neurological deficits after a mean follow-up time of 4.5 months. No cardiovascular adverse events attributed to milrinone were observed.
  
  
  CONCLUSIONS
  Milrinone may be a useful supplementary substance for endovascular VSP therapy. Aggressive reintervention indications did not cause additional adverse events.
authors.affiliation: Department of Neurosurgery, Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030, Vienna, Austria, camillo.sherif@cerebrovascular.at.
authors.forename: Camillo
authors.initials: C
authors.lastname: Sherif
authors.forename: Bernhard
authors.initials: B
authors.lastname: Wambacher
authors.forename: Michel
authors.initials: M
authors.lastname: Loyoddin
authors.forename: Radenko
authors.initials: R
authors.lastname: Karaic
authors.forename: Peter
authors.initials: P
authors.lastname: Krafft
authors.forename: Andreas
authors.initials: A
authors.lastname: Valentin
authors.forename: Dimiter
authors.initials: D
authors.lastname: Tscholakoff
authors.forename: Guenther
authors.initials: G
authors.lastname: Kleinpeter
mesh_terms: D000328:Adult; D003131:Combined Modality Therapy; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D020105:Milrinone / Q000008:administration & dosage*; D009553:Nimodipine / Q000008:administration & dosage*; D010865:Pilot Projects; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000188:drug therapy* / Q000601:surgery; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial; D014665:Vasodilator Agents / Q000008:administration & dosage; D020301:Vasospasm, Intracranial / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery
chemical_list: D014665:Vasodilator Agents; D009553:Nimodipine; D020105:Milrinone