(600) Cardiac Arrest With Verapamil Use in aSAH Vasospasm Treatment

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) is a highly morbid type of hemorrhagic stroke. The release of cytokines and catecholamines can lead to delayed cerebral ischemia (DCI) and takotsubo cardiomyopathy complicating treatment, worsening outcomes, and increasing mortality of aSAH. When treating vasospasm, it is critical that clinicians select treatment options to elevate aSAH patient’s mean arterial pressures (MAPs), maintain euvolemia, and augment cerebral perfusion while considering their cardiopulmonary effects.

Description: A 52-year old female presented to the hospital after a fall and found to have an aSAH. A diagnostic angiogram found a multilobulated anterior communicating artery aneurysm that was secured by WEB embolization. Her stay was complicated by delayed cerebral ischemia initially treated with intra-arterial (IA) verapamil and nitroglycerine. She then developed an increasing vasopressor requirement to maintain hyperdynamic therapy and an echo showed hypokinetic midsegments with reduced function concerning for an atypical takotsubo cardiomyopathy. With worsening clinical symptoms of vasospasm she returned to IR for repeat treatment. Shortly after administration of 10 mg IA verapamil the patient had a cardiac arrest. ROSC was achieved after 4 minutes and she had emergent balloon pump placement. The patient returned to IR for vasospasm treatment a day after her arrest where she received IA milrinone and was placed on systemic milrinone for heart failure and vasospasm treatment. A repeat echo a few days later showed resolution of takotsubo cardiomyopathy and a recovery of function.

Discussion: In aSAH patients complicated with takotsubo cardiomyopathy and DCI, calcium channel blockers should be avoided. While verapamil is widely used for vasospasm treatment, its negative inotropic effects may worsen outcomes for these patients. Milrinone should be considered a therapeutic option for these patients. Milrinone is a vasodilator with positive inotropic effects. Literature supports intra-arterial infusions of milrinone followed by adjunctive intravenous infusions as a promising treatment regimen for cerebral vasospasm. While this case highlights the risk of verapamil and utility of milrinone in aSAH patients with both vasospasm and reduced EF, further research is warranted.