1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia.
2Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, Georgia.
J Neurosurg. 2021 Jun 4;136(1):115-124. doi: 10.3171/2020.12.JNS203673. Print 2022 Jan 1.
Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication.
Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events.
The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44-0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61-2.91).
IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.
蛛网膜下腔出血（SAH）后，脑血管痉挛和迟发性脑缺血（DCI）导致预后不良。由于缺乏有效的治疗方法，作者描述了他们在这种情况下使用鞘内（IT）尼卡地平的经验。
纳入 2012 年至 2017 年间因非创伤性 SAH 入住埃默里大学医院神经科学 ICU 的患者，包括动脉瘤性或特发性 SAH。使用倾向评分模型，将该患者队列与未接受 IT 尼卡地平的蛛网膜下腔出血国际试验者（SAHIT）数据库中的患者进行比较。主要结局为 DCI。次要结局为长期功能结局和不良事件。
分析纳入了 1351 例患者，其中 422 例诊断为脑血管痉挛并接受 IT 尼卡地平治疗。与无血管痉挛患者（n=859）相比，治疗组患者明显更年轻（平均年龄 51.1±12.4 岁 vs. 56.7±14.1 岁，p<0.001），世界神经外科学会评分和改良 Fisher 分级更高，更倾向于接受破裂动脉瘤夹闭术而非血管内治疗（30.3% vs. 11.3%，p<0.001）。在 77.3%的治疗患者中，IT 尼卡地平治疗降低了每日平均经颅多普勒速度。与未接受 IT 尼卡地平治疗的患者相比，治疗并未增加细菌性脑室炎的发生率（3.1% vs. 2.7%，p>0.1），但脑室-腹腔分流术的发生率更高（19.9% vs. 8.8%，p<0.01）。与 SAHIT 数据库进行倾向评分比较后，IT 尼卡地平治疗发生 DCI 的比值比（OR）为 0.61（95%置信区间 [CI] 0.44-0.84），功能结局良好（改良 Rankin 量表评分≤2）的 OR 为 2.17（95%CI 1.61-2.91）。
与匹配的对照组相比，IT 尼卡地平治疗可改善结局并减少 DCI。但需要永久性脑脊液分流的几率增加，但无其他安全问题。在选择药物和治疗方法进行未来的 SAH 随机对照临床试验时，应考虑这些数据。
