Correlation of intraventricular nicardipine for refractory vasospasm in aneurysmal subarachnoid hemorrhage with improved neurophysiology on intracranial multimodality monitoring: illustrative case

BACKGROUND: Cerebral vasospasm after aneurysmal subarachnoid hemorrhage can lead to considerable mortality and morbidity affecting the intracranial vessels, leading to delayed cerebral ischemia and stroke. Therapeutic options for patients with treatment-refractory vasospasm are limited, particularly in the setting of significant cardiopulmonary disease. Administration of nicardipine, a calcium channel blocker, into the intrathecal space may represent a potential treatment option for this population. OBSERVATIONS: A 56-year-old woman had treatment-refractory vasospasm, severe acute respiratory distress syndrome, and Takotsubo cardiomyopathy. As an adjunct to vasopressor administration and endovascular intraarterial calcium channel blocker administration, the patient received intraventricular nicardipine. The patient demonstrated improved neurophysiology on invasive multimodality neuromonitoring, with increased cerebral blood flow and oxygenation as a result of intraventricular nicardipine administration. LESSONS: Intraventricular nicardipine can be used as rescue therapy for patients with treatment-refractory cerebral vasospasm. This case demonstrates that intrathecal nicardipine may prevent delayed ischemic neurological deficits and improve outcomes.