PDF: CIAN
(2022)Objective
To evaluate the safety and outcome in aneurysmal subarachnoid hemorrhage patients treated with continuous intraarterial nimodipine infusion for delayed cerebral ischemia with large vessel vasospasm
Study Summary
• Minor cerebral infarctions occurred in 5 patients (29%), major infarctions in 3 patients (18%)
• One death occurred due to posthemorrhagic cerebral edema
Intervention
Continuous intraarterial nimodipine infusion (0.5-2.0 mg/h) administered through microcatheters placed in extracranial internal carotid and/or vertebral artery for median 5 days
Inclusion Criteria
Adult patients with aneurysmal SAH, delayed cerebral ischemia with severe therapy-refractory large vessel vasospasm (>75% narrowing) or moderate vasospasm with persistent symptoms despite short-term intraarterial nimodipine, perfusion deficits on CT perfusion
Study Design
Arms: Single arm: Continuous intraarterial nimodipine infusion
Patients per Arm: 17 patients total
Outcome
• GOS 4-5 at 1 year: 13 patients (76%)
• DCI-related infarctions: 8 patients (47% - 5 minor, 3 major)
Bottom Line
Continuous intraarterial nimodipine infusion resulted in favorable outcomes in 76% of patients within 1 year, with acceptable safety profile. The technique may be used to treat patients with severe therapy-refractory delayed cerebral ischemia after SAH.
Major Points
- Retrospective single-center cohort study of 17 patients treated with CIAN between May 2016 and December 2017
- CIAN initiated median 9 days after SAH with median duration of 5 days
- Nimodipine administered at 0.5-2.0 mg/h through microcatheters in extracranial ICA and/or vertebral artery
- Favorable outcome (GOS 4-5) in 53% at discharge, improved to 76% at 1-year follow-up
- DCI-related infarctions occurred in 8/17 patients (47%): 5 minor and 3 major
- One death due to posthemorrhagic cerebral edema
- Treatment response monitored with TCD, CT perfusion, CT angiography, and DSA
- All awake patients showed immediate clinical improvement after CIAN initiation
- Complications included catheter pressure elevation (5 catheters in 4 patients) and accidental removal (2 patients)
- One patient developed localized cerebral edema possibly due to CIAN
- Antiplatelet therapy with tirofiban used to prevent catheter-related thromboembolism
Study Design
- Study Type
- Retrospective, single-center cohort study
- Randomization
- No
- Blinding
- Blinded neuroradiologist for reevaluation of radiographic data
- Sample Size
- 17
- Follow-up
- Up to 1 year (median 12 months, range 6-12 months)
- Centers
- 1
- Countries
- Germany
Primary Outcome
Definition: Glasgow Outcome Scale at discharge and at follow-up within 1 year, and presence of cerebral infarction on final CT scan prior to discharge (minor: <1/3 vessel territory; major: >1/3 vessel territory)
| Control | Intervention | HR/OR | P-value |
|---|---|---|---|
| GOS 4-5 at discharge: 9 (53%); GOS 4-5 at 1 year: 13 (76%); Minor infarctions: 5 (29%); Major infarctions: 3 (18%) | - |
Limitations & Criticisms
- Retrospective single-center design limits generalizability
- No control group for comparison
- Small sample size (n=17) limits statistical power
- Selection bias as protocol weighted cerebral hypoperfusion on PCT heavily for CIAN indication
- Follow-up data missing for 4 patients at 1 year
- No routine MRI performed which may have underestimated infarction rates
- Classification of infarctions by volume doesn't account for eloquent area involvement
- Long-term follow-up beyond 1 year not available
- Few patients underwent TBA or short-term intraarterial nimodipine before CIAN, making comparison difficult
- Open-label treatment without blinding
- Monitoring strategy (TCD every 6 months with symptom-driven assessments) may have underestimated AF recurrence
- Variability in follow-up imaging timing and protocols
- Did not use multimodal neuromonitoring (PtiO2, pyruvate metabolism) which some centers employ
Citation
Front. Neurol. 13:829938