1. Home>
2. Specialties>
3. Neurology>
4. Summary and Comment

Intrathecal Nitroprusside Treatment for Vasospasm

For patients with subarachnoid hemorrhage and vasospasm who fail conventional treatment, intrathecal nitroprusside may be an alternative -- though not necessarily equally effective -- treatment.

Treatment of critically ill patients with subarachnoid hemorrhage (SAH) has focused on preventing delayed ischemic deficits associated with vasospasm. Hypervolemic hypertensive hemodilutional (HHH) therapy and endovascular treatment with papaverine and angioplasty are typically used, but widespread strokes may still develop in patients with vasospasm that is refractory to treatment. These authors report their safety experience using intrathecal sodium nitroprusside and thiosulfate (ITSNP/T) in 10 SAH patients. The patients were critically ill, had existing external ventricular drains placed as routine care for SAH, and had transcranial evidence of vasospasm. In addition to ITSNP/T therapy, conventional HHH therapy was given to all patients and angioplasty was performed where indicated (3 patients). The authors' hypothesis was that the ITSNP/T therapy was safe.

The researchers measured the clinical and physiologic effects of ITSNP/T using transcranial Doppler (TCD) ultrasound and intracranial pressure (ICP) monitoring. In 7 of the 10 patients, ITSNP/T resulted in a decrease in TCD velocities with no increase in ICP. Another patient had improved cerebral transit time after treatment. These results indicate that vasodilatation occurred with ITSNP/T as predicted. Six patients experienced serious nausea and vomiting despite pretreatment, and 1 patient had induced hypotension. However, no deaths or serious adverse effects occurred with this treatment, and the overall outcome is consistent with modern neurointensive care statistics.

Comment: Experience has shown that invasive aggressive measures are sometimes needed -- and effective -- in critically ill patients. I applaud these authors for this study. More research on the dosing and timing of treatment, and on its effect on outcome, is needed, however. I am concerned about vomiting and aspiration with ITSNP/T, but many SAH patients with vasospasm are comatose and may not be adversely affected. Most SAH patients tolerate and benefit from HHH therapy and angioplasty, and these treatments remain the mainstays of therapy. The current study does not show that ITSNP/T would be as effective as a replacement or alternative strategy for vasospasm. Nonetheless, it may become another tool to treat vasospasm when conventional aggressive treatment fails.

— Paul M. Vespa, MD

Dr. Vespa is Assistant Professor of Neurosurgery and Neurology and Director of Neurocritical Care, University of California, Los Angeles.

Published in Journal Watch Neurology June 27, 2002

Citation(s):

Thomas JE and McGinnis G. Safety of intraventricular sodium nitroprusside and thiosulfate for the treatment of cerebral vasospasm in the intensive care unit setting. Stroke 2002 Feb; 33:486-92.

• Original article (Subscription may be required)
• Medline abstract (Free)