Cerebral vasospasm (CVS) is a complication of aSAH occurring in up to 40-70% of patients. There has been an association between CVS and delayed cerebral ischemia (DCI) which is attributed to the morbidity and mortality following aSAH. Some patients with CVS respond to blood pressure augmentation, but many go on to develop delayed ischemic neurologic deficits despite aggressive therapy. There is some suggestion in the literature that intraventricular milrinone (IVtM) may be useful in the treatment of CVS.

Retrospective analysis of patients with aSAH treated with IVtM at a single tertiary center from 2016-2018. Patients were treated with IVtM if they had symptomatic CVS or TCD suggestive of critical CVS that persisted despite BP augmentation or endovascular therapies. Nimodipine was given as standard of care.  A subset of patients were also treated with intravenous milrinone (IVM), which was dosed in a standard fashion based on Montreal Neurological Institute protocol.  We collected demographic data, TCD mean flow velocity (MFV) and pulsatility index (PI), as well as utilization and frequency of IVtM and IVM.

Twenty-eight patients had median modified Fisher of 4 (IQR 3,4) and median Hunt-Hess score of 3 (IQR 2, 4). Twenty-one of 28 patients were treated with IVtM+IVM.  Seven (25%) who received IVtM alone had no significant improvement in MFV or PI. Median doses of IVtM was 10 (IQR 5,14). There was no significant improvement with number of IVtM doses.  The number of IVtM doses correlated with an increased discharge mRS (p=0.05).  There were no direct complications due to IVtM or IVM.

Neither IVtM+IVM nor IVtM alone appear to be effective treatment of CVS in aSAH. Our data represent one of the first case series reporting IVtM +/- IVM utilization for treatment of CVS.