Anesthetic considerations for selective ia nicardipine injection for intracranial vasospasm

Marcos M. Soliman, MD, Rafi Avitsian, MD. Department of General Anesthesia, Cleveland Clinic, Cleveland, Ohio, United States. Introduction: Cerebral vasospasm after subarachnoid hemorrhage (SAH) can decrease cerebral blood flow worsening the clinical picture. Induction of hypertension, hypervolemia and hemodilution is the accepted medical therapy to decrease the ischemic effects of vasospasm. Selective intra-arterial injection of Nicardipine during angiography has been suggested to relieve vasospasm. We are reporting the hemodynamic changes in 11 patients who underwent this procedure. Materials and Methods: After institutional review board approval, we conducted a retrospective chart review of 15 procedures in 11 patients. Collected data included age, sex, post bleed day (PBD), pre-procedure intubation status in the intensive care unit, systolic (SBP) mean (MAP) and diastolic (DBP) blood pressure and heart rate (HR) as well as use of inotropes (Table 1). Mean change (and 95% CI) in SBP, MAP, DBP and heart rate (HR) with intraarterial injection of Nicardipine was calculated using paired t-test. Hemodynamic changes from baseline between genders were compared using Wilcoxon rank-sum test, and correlation between these changes and both age and PBD were calculated using Pearson correlation. Results: There was a significant change in blood pressure after injection of Nicardipine (Table 2). Hemodynamic changes were not significantly correlated with age or PBD. Blood pressure changes were not different between genders, but increase in HR was higher for females (P=0.022). A significantly higher drop in SBP (P=0.033) but not for DBP or MAP after injection was seen in patients who were not intubated in NICU before the procedure. Conclusion: Selective intra-arterial injection of Nicardipine during angiography can cause significant hemodynamic effects and would need supportive management by the anesthesiologist. Close hemodynamic monitoring and addition or increase in dose of inotropic agent(s) is important through transportation to neuroradiology suite, through the procedure and afterwards to ensure adequate perfusion of the brain.