Neurocritical Care

Role of nicotine replacement therapy (NRT) – Smoking is a common risk factor for developing cerebral

aneurysms.

Nicotine administration to naive users causes vasoconstriction, whereas administration to

heavy users causes little reaction. Nicotine withdrawal in heavy users causes acute, temporary

vasodilation, which may lead to headaches.

Seder et al.: Neurocrit Care 2011;14:77-83: Evaluated safety of NRT in active cigarette smokers

admitted with an aneurysmal SAH and included 128 who received NRT and 106 who did not.

Despite its vasoactive properties, NRT administered among active smokers with acute aneurysmal

SAH appeared safe, with similar rates of vasospasm and delayed cerebral ischemia and a slightly

higher rate of seizures.

disposition among neurosurgery ICU patients who were smokers treated with NRT (n=114), smokers

not treated with NRT (n=113), and nonsmokers not treated with NRT (n=113). Primary admitting

diagnosis for neurosurgery patients included SAH, ICH, other trauma, and elective neurosurgery.

Administration technique -- typically administered during cerebral angiography

infusion”)

Calcium channel blockers

Typically used for cerebral vasospasm associated with SAH

Direct, local infusion typically results in immediate vasodilation.

Usually effective in proximal and distal vessels

verapamil vs. nicardipine plus verapamil plus nitroglycerin) for arterial lumen restoration post-cerebral

vasospasm after aneurysmal SAH (Intra-arterial Vasospasm Trial at https://clinicaltrials.gov/ct2/show/

record/NCT01996436).

Agent

Typical Dose

Adverse Effects

Nicardipine

2–25 mg, up to 5

mg/vessel

Systemic hypotension

Increased ICP

Verapamil

1–10 mg

Systemic hypotension

Bradycardia

Increased ICP

Milrinone

5–15 mg

Systemic hypotension

ICP = intracranial pressure.

Most often used in patients with ischemic stroke

Current roles