Feasibility of intraventricular nicardipine prolonged release implants in patients following aneurysmal subarachnoid haemorrhage

ArticleinBritish Journal of Neurosurgery 25(6):677-83 · February 2011with12 Reads
DOI: 10.3109/02688697.2010.548878 · Source: PubMed
Abstract
Intracisternal nicardipine prolonged release implants (NPRI) have been shown to be effective in the prophylaxis of cerebral vasospasm (VS). However, they cannot be used in patients following coil occlusion of the aneurysm. As a certain dissemination of nicardipine within the cerebrospinal fluid (CSF) has been described, we examined the feasibility of intraventricular use of NPRI in patients that underwent clip and coil occlusion of their aneurysms following aneurysmal subarachnoid haemorrhage (aSAH). By comparison with an historical control group, an estimation of their effectivity in regard to angiographic vasospasm and the development of cerebral infarction has been performed. Thirty-one patients suffering from aSAH were prospectively included in this trial. Study participants received prior to clipping (n = 17) or coiling (n = 14) 6 (n = 15) or 10 NPRI (n = 16) into the lateral ventricles. Physiological data were collected, proximal and global VS were determined using pre-operative and day 8 ± 1 angiography, and incidence of hydrocephalus and VS related infarcts were evaluated and compared to a historical control group consisting of 16 operated patients without NPRI implantation. Intraventricular NPRI were tolerated well. There were no adverse side effects detectable, physiological variables such as heart rate (HR), mean arterial blood pressure (MAP), intracranial pressure (ICP) and electrolytes showed no difference compared to control. There was no difference in the proportion of patients that required CSF shunting. A significant positive angiographic effect could only be observed in clipped patients (proximal vessel diameters: control, 80 ± 30%; NPRI 90 ± 24%; incidence of moderate/severe global VS: control, 73%; NPRI, 41%). The use of intraventricular NPRI seems to be safe and tolerated well. There is preliminary evidence for effectivity on angiographic VS for clipped patients only. A further increase of the effective dose might also exert efficacy in the subset of patients following coil occlusion.
    • "The recent increased employment of endovascular coiling treatment in patients with aSAH allows for the development of a novel implantation strategy for nicardipine pellets in order to manage cerebral vasospasm. Indeed, Barth and his coinvestigators [108] recently reported the implantation of NPRIs in the ventricular system of patients undergoing coiling procedures for ruptured aneurysms. They found that NPRIs intraventricular implantation had no problems, and no adverse events or side effects were detected in their cohort. "
    [Show abstract] [Hide abstract] ABSTRACT: Aneurysmal subarachnoid hemorrhage- (aSAH-) associated vasospasm constitutes a clinicopathological entity, in which reversible vasculopathy, impaired autoregulatory function, and hypovolemia take place, and lead to the reduction of cerebral perfusion and finally ischemia. Cerebral vasospasm begins most often on the third day after the ictal event and reaches the maximum on the 5th-7th postictal days. Several therapeutic modalities have been employed for preventing or reversing cerebral vasospasm. Triple "H" therapy, balloon and chemical angioplasty with superselective intra-arterial injection of vasodilators, administration of substances like magnesium sulfate, statins, fasudil hydrochloride, erythropoietin, endothelin-1 antagonists, nitric oxide progenitors, and sildenafil, are some of the therapeutic protocols, which are currently employed for managing patients with aSAH. Intense pathophysiological mechanism research has led to the identification of various mediators of cerebral vasospasm, such as endothelium-derived, vascular smooth muscle-derived, proinflammatory mediators, cytokines and adhesion molecules, stress-induced gene activation, and platelet-derived growth factors. Oral, intravenous, or intra-arterial administration of antagonists of these mediators has been suggested for treating patients suffering a-SAH vasospam. In our current study, we attempt to summate all the available pharmacological treatment modalities for managing vasospasm.
    Full-text · Article · Jan 2013
  • [Show abstract] [Hide abstract] ABSTRACT: Despite considerable effort, no effective prophylactic treatment for cerebral vasospasm after subarachnoid haemorrhage (SAH) has been identified thus far. Treatment approaches have included the application of intravenous and therefore systemic vasodilatory drugs, which in turn have been found to be associated with significant side effects while at the same time exerting only limited efficacy. Consequently, a more local application, namely the intrathecal delivery of nicardipine prolonged-release implants (NPRI) has been developed. After surgical clipping of the causative aneurysm, these implants may be positioned adjacent to the proximal vasculature most at risk for developing delayed vasospasm. Several studies were able to show a dramatic reduction in both the incidence and severity of angiographic vasospasm, which in turn reduces the development of cerebral infarction and delayed ischaemic neurological deficits. While efficacy appears to be dose dependent, a reduction of angiographic vasospasm incidence from 70% to less than 10% has been observed, paralleled by an improvement of functional outcome. However, when applied intraventricularly after coiling of the offending aneurysm, effects were less pronounced. At this time, NPRIs seem to represent a very promising treatment option for the prevention of cerebral vasospasm after SAH, and larger studies will be needed to further supplement previous findings.
    Article · Jan 2011
  • [Show abstract] [Hide abstract] ABSTRACT: Nicardipine prolonged release implants (NPRI) have been shown to decrease the incidence of cerebral vasospasm and infarcts significantly in patients after aneurysmal subarachnoid haemorrhage (SAH) following microsurgical clipping. Yet, the comparison with results after endovascular coiling is lacking. This study was conducted to determine the differences in the incidence of cerebral vasospasm and infarctions between those two treatment modalities The design of this investigation reflects a case-control study; 27 patients suffering from acute SAH were treated by microsurgical clipping and received an intracisternal implantation of NPRI. Twenty-seven matching consecutive patients after microsurgical treatment without implantation of NPRI or endovascular treatment, respectively, served as controls. The incidence of angiographic vasospasm and cerebral infarctions were documented. All groups were comparable concerning demographics and severity of SAH. Twenty-four of 81 patients developed angiographic vasospasm (>33% constriction). The incidence of vasospasm was 48%, 44% and 11% for patients after endovascular treatment, microsurgical clipping without NPRI and microsurgical clipping with NPRI, respectively. New cerebral infarctions occurred in 28%, 22% and 7% of the treated patients, respectively. A good clinical recovery 1 year after the initial bleeding (modified Rankin scale 0-2) was seen in 48%, 50% and 77% of the treated patients, respectively. The use of NPRI during microsurgical clipping was confirmed to be safe and effective. Patients who received intracisternally implanted NPRI during clipping after aneurysmal SAH yielded significantly lower vasospasm and infarction rates, and showed a better clinical outcome when compared with clipping without NPRI and also when compared with endovascular coiling.
    Article · Aug 2011
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