Fraticelli Amanda Tarabini, Cholley Bernard P, Losser Marie-Reine, Saint Maurice Jean-Pierre, Payen Didier
Département d'Anesthésie-Réanimation-SMUR, Hôpital Lariboisière, 2 rue Ambroise Paré, 75475 Paris cedex 10, France.
Stroke. 2008 Mar;39(3):893-8. doi: 10.1161/STROKEAHA.107.492447. Epub 2008 Jan 31.
Attempts to reverse cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH) rely on a limited number of treatments. Calcium channel blockers have proven a benefit but their vasodilating effect on spastic cerebral arteries is relatively modest. Milrinone, a phosphodiesterase inhibitor, combines vasodilating and inotropic properties, but limited data exist to support its use for the treatment of CVS. We assessed the efficacy and tolerance of milrinone in patients with CVS secondary to aSAH.
Twenty-two consecutive patients with angiographically-proven CVS (arterial diameter reduction >40%) have been studied. Intraarterial milrinone was infused in the cerebral territory(ies) involved and followed by continuous intravenous infusion until Day 14 after initial bleeding. We evaluated angiographic reversal of CVS, hemodynamic tolerance, and neurological outcome 1 year after aSAH.
Thirty-four selective intraarterial infusions of milrinone were required to treat 72 vasospastic territories. Intraarterial milrinone resulted in 53+/-37% increase in arterial diameter (P<.0001). Milrinone infusion resulted in moderately increased heart rate, but systemic arterial pressure remained unchanged. Five patients (23%) had angiographically-proven vasospasm recurrence within 48 hours after the procedure. Two of them were successfully reversed after another intraarterial infusion of milrinone. The remaining 3 underwent mechanical angioplasty. Two patients (9%) died in ICU, and 2 were lost to follow-up. All other patients had very good neurological outcome (modified Rankin scale: 0.8+/-1.0; Barthel index: 100 [95-100]).
This study suggests that milrinone is effective and safe for reversal of CVS after aSAH and should be tested in a large randomized trial.
动脉瘤性蛛网膜下腔出血（aSAH）后逆转脑血管痉挛（CVS）的尝试依赖于有限的几种治疗方法。钙通道阻滞剂已被证明有一定益处，但其对痉挛性脑动脉的舒张作用相对较弱。米力农是一种磷酸二酯酶抑制剂，兼具血管舒张和正性肌力特性，但支持其用于治疗CVS的数据有限。我们评估了米力农治疗aSAH继发CVS患者的疗效和耐受性。
对连续22例经血管造影证实存在CVS（动脉直径缩小>40%）的患者进行了研究。将米力农经动脉注入受累的脑区，随后持续静脉输注直至初次出血后第14天。我们评估了aSAH后1年CVS的血管造影逆转情况、血流动力学耐受性和神经功能结局。
治疗72个血管痉挛区域需要34次选择性动脉内注入米力农。动脉内注入米力农使动脉直径增加了53±37%（P<0.0001）。米力农输注使心率适度增加，但体动脉压保持不变。5例患者（23%）在术后48小时内血管造影证实出现血管痉挛复发。其中2例在再次动脉内注入米力农后成功逆转。其余3例接受了机械血管成形术。2例患者（9%）在重症监护病房死亡，2例失访。所有其他患者神经功能结局均非常好（改良Rankin量表：0.8±1.0；Barthel指数：100[95 - 100]）。
本研究表明，米力农对aSAH后逆转CVS有效且安全，应在大型随机试验中进行检验。
