Milrinone for refractory cerebral vasospasm with delayed cerebral ischemia
Milrinone for refractory cerebral vasospasm with delayed cerebral ischemia
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DOI：
10.3171/2020.1.jns193107
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发表时间：
2020-03-01
影响因子：
4.1
通讯作者：
Angle, Mark R.
中科院分区：
文献类型：
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作者：
Abulhasan, Yasser B.;Jimenez, Johanna Ortiz;Angle, Mark R.
目的静脉注射米立酮是治疗动脉瘤性蛛网膜下腔出血（aSAH）后脑血管痉挛伴迟发性脑缺血（DCI）的一种有希望的治疗方法。然而，静脉注射米力农治疗标准治疗难治性病例的疗效数据仍然有限。本研究的目的是确定静脉注射米立酮后难治性血管痉挛/DCI的预测因素，并分析动脉内注射（IA）米立酮和/或机械血管成形术的挽救治疗结果。方法：作者对2010年至2016年在蒙特利尔神经病学研究所和医院住院的所有aSAH患者进行了回顾性队列研究。患者分为3组：无DCI、标准治疗和抢救治疗。主要终点是出院前神经影像学检查发现的dci相关脑梗死的频率。次要结局包括修正Rankin量表（mRS）评分报告的功能结局，以及难治性血管痉挛的节段逆转。结果共纳入322例患者：无DCI组212例，标准治疗组89例，抢救治疗组21例。大约一半（52%,168/322）患者在治疗决定时被诊断为不良aSAH（世界神经外科学会联合会分级III-V级）。在DCI和影像学评估血管痉挛严重程度的患者中，62%（68/109）的DCI表现为中度/重度放射学血管痉挛。19%（21/110）的患者出现难治性血管痉挛/DCI，并接受了抢救治疗。IA米力酮的靶向挽救治疗逆转了32%（29/91）的难治性血管痉挛血管，76%（16/21）的患者在开始治疗后24小时内神经系统状态显著改善。中度/重度放射性室间隔痉挛独立预测是否需要抢救治疗（OR 27, 95% CI 8.01-112）。在出院前进行神经影像学检查的患者中，40%（112/277）发生了新的脑梗死，其中只有21%（23/112）与血管痉挛有关。总体而言，65%（204/314）的患者在aSAH后中位4个月（四分位数范围2-8个月）评估的功能结局（mRS评分0-2）良好，三组之间的功能结局无差异（p = 0.512）。结论：基于该回顾性研究队列，积极使用米力农是安全有效的，是治疗aSAH后血管痉挛/DCI的一种有希望的治疗方法。https://thejns.org/doi/abs/10.3171/2020.1.JNS193107
OBJECTIVE Intravenous (IV) milrinone is a promising option for the treatment of cerebral vasospasm with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). However, data remain limited on the efficacy of treating cases that are refractory to standard therapy with IV milrinone. The aim of this study was to determine predictors of refractory vasospasm/DCI despite treatment with IV milrinone, and to analyze the outcome of rescue therapy with intraarterial (IA) milrinone and/or mechanical angioplasty.METHODS The authors conducted a retrospective cohort study of all patients with aSAH admitted between 2010 and 2016 to the Montreal Neurological Institute and Hospital. Patients were stratified into 3 groups: no DCI, standard therapy, and rescue therapy. The primary outcome was frequency of DCI-related cerebral infarction identified on neuroimaging before hospital discharge. Secondary outcomes included functional outcome reported as modified Rankin Scale (mRS) score, and segment reversal of refractory vasospasm.RESULTS The cohort included 322 patients: 212 in the no DCI group, 89 in the standard therapy group, and 21 in the rescue therapy group. Approximately half (52%, 168/322) were admitted with poor-grade aSAH at treatment decision (World Federation of Neurosurgical Societies grade III-V). Among patients with DCI and imaging assessing severity of vasospasm, 62% (68/109) had moderate/severe radiological vasospasm on DCI presentation. Nineteen percent (21/110) of patients had refractory vasospasm/DCI and were treated with rescue therapy. Targeted rescue therapy with IA milrinone reversed 32% (29/91) of the refractory vasospastic vessels, and 76% (16/21) of those patients experienced significant improvement in their neurological status within 24 hours of initiating therapy. Moderate/severe radiological va- sospasm independently predicted the need for rescue therapy (OR 27, 95% CI 8.01-112). Of patients with neuroimaging before discharge, 40% (112/277) had developed new cerebral infarcts, and only 21% (23/112) of these were vasospasmrelated. Overall, 65% (204/314) of patients had a favorable functional outcome (mRS score 0-2) assessed at a median of 4 months (interquartile range 2-8 months) after aSAH, and there was no difference in functional outcome between the 3 groups (p = 0.512).CONCLUSIONS The aggressive use of milrinone was safe and effective based on this retrospective study cohort and is a promising therapy for the treatment of vasospasm/DCI after aSAH. https://thejns.org/doi/abs/10.3171/2020.1.JNS193107