Authors :
Presenting Author: Rachel Pauley, MD – Northwestern University Feinberg School of Medicine
Sue Hong, MD – Attending Physician, Critical Care, Northwestern University Feinberg School of Medicine; Divakar Mithal, MD, PhD – Attending Physician, Neurology, Northwestern University Feinberg School of Medicine
Rationale:
Intrathecal nicardipine is an emerging therapy for cerebral vasospasm with limited data for children. This case reviews the use of intrathecal nicardipine for pediatric cerebral vasospasm and shows a correlation of quantitative EEG with clinical efficacy.
Methods:
Chart Review
Results:
A 12-year-old female presented with fever, headache, encephalopathy, and multiple cranial neuropathies. Neuroimaging was consistent with meningitis, sinusitis, ventriculitis, nonocclusive cerebral venous sinus thromboses, and communicating hydrocephalus. Initial magnetic resonance angiography (MRA) of the head was normal.
Streptococcus pneumoniae was detected in cerebral spinal fluid. She underwent endoscopic sinus surgery and external ventricular drain (EVD) placement. On postoperative day four, she developed left-sided weakness and focal seizures, and was treated with anti-seizure medications. Video EEG showed asymmetric bihemispheric slowing, worse in the right hemisphere, with no seizures captured. Repeat neuroimaging revealed vasospasm of the right middle cerebral artery (MCA) with no associated ischemia. Intrathecal nicardipine was administered through the EVD every eight hours for five days. Sedation limited the physical examination, but following each intrathecal nicardipine dose,
the EEG background became transiently symmetric. The symmetry corresponded with higher frequencies, amplitudes, and powers in the right hemisphere on quantitative EEG. Following intrathecal treatment, she had resolution of left-sided weakness and right MCA narrowing on repeat MRA. She transitioned to a three week course of oral nimodipine. Outpatient follow-up at three months showed no deficits.
Conclusions:
Intrathecal nicardipine is a treatment for cerebral vasospasm in aneurysmal subarachnoid hemorrhage in adults, with studies showing improvement in angiographic and clinical vasospasm. However, intrathecal nicardipine remains a novel therapy for pediatric cerebral vasospasm with only a few cases reported in the literature. Our case illustrates efficacy and safety with an excellent outcome. Quantitative EEG is a noninvasive, continuous monitoring tool that can detect alterations in cerebral perfusion, which can precede changes on exam and imaging. Notably, quantitative EEG detected real-time improvements associated with intrathecal nicardipine delivery, suggesting utility as a biomarker of clinical efficacy.
Funding: The authors have no sources of funding to report for this abstract.