Cerebral vasospasm due to aneurysmal and diffuse non-aneurysmal subarachnoid hemorrhage: A single center experience

Introduction After direct mortality from an aneurysmal subarachnoid hemorrhage (aSAH), delayed cerebral ischemia (DCI) secondary to cerebral vasospasm is a cause of severe morbidity and mortality. Distinct from perimesencephalic SAH with favorable prognosis, non-aneurysmal diffuse SAH has been observed to have a more variable outcome and requires close clinical observation as this subset of patients has a higher likelihood for developing DCI. Treatment of radiographic and clinical vasospasm is limited to only a few pharmacological agents with varying degrees of success. Several recent publications have demonstrated efficacy with using intravenous (IV) milrinone to treat cerebral vasospasm. Here, we audit the use of IV milrinone in the clinical management of vasospasm and DCI in an adult non-aneurysmal SAH population. Methods A retrospective quality audit was conducted at a single neurosurgical center over a 1-year period (2019). Data was extracted from electronic medical records. Results A total of 93 adult patients were admitted for management of SAH. Twenty-four patients presented with non-aneurysmal SAH. Four patients in this group required symptomatic DCI management. All 4 patients presented with a diffuse pattern of SAH. Two of these patients presented with acute hydrocephalus requiring external ventricular drain (EVD) insertion. Most non-aneurysmal SAH patients had a good clinical outcome (92%, mRS 0–2). Two patients had a poor clinical outcome (mRS 3 and 4) at clinical follow up. These two patients initially presented with a poor clinicoradiological grading score and one patient required an urgent EVD for acute hydrocephalus. Intravenous milrinone was commenced for reduced level of consciousness (LOC) in 2/4 patients, while focal neurological deficit prompted initiation of IV therapy in the remaining 2. Conclusion Patients with diffuse non-aneurysmal SAH can develop symptomatic DCI and should be closely monitored and provided a standardized protocol for cerebral hyperdynamic therapy.