Geç Serebral İskemide İntraarteriyel Milrinon Tedavisi: Fonksiyonel Bağımlılık ve Mortalite Üzerine Etkisi

Öz

Anevrizmal subaraknoid kanamaya (aSAK) bağlı geç serebral iskemi (GSİ) önemli bir mortalite ve morbidite etkenidir. GSİ tedavisinde oral nimodipin, normovolemi ve indüklenmiş hipertansiyon tedavilerinin yanı sıra endovasküler yöntemle intraarteriyel (İA) vazodilatörler kullanılmaktadır. Bu ajanlardan biri de fosfodiestera-3 inhibitörü olan milrinondur. Çalışmamızda İA milrinon verilen ve standart GSİ tedavisi uygulanan hastalar karşılaştırmalı analiz edilerek milrinon tedavisinin uzun dönem hasta sonuçlarına etkisi araştırılmıştır. Mevcut çalışmada Ocak 2023 ile Haziran 2024 tarihleri arasında merkezimizde tedavi edilen aSAK olguları arasından GSİ gelişen 60 hastanın retrospektif kontrollü analizi yapılmıştır. Hastaların 35’ine yalnızca standart GSİ tedavisi verilmiştir. 25 olguya standart tedaviye ek İA milrinon uygulanmıştır. Milrinon tedavisine bağlı ciddi ve kalıcı bir komplikasyon izlenmemiştir. Klinik ve radyolojik veriler karşılaştırılmış; fonksiyonel sonuçlar 6. ayda modifiye Rankin skalası skoru ile, sağkalım ise ölüm oranları ile değerlendirilmiştir. Milrinon tedavisinin mortalite ve fonksiyonel bağımlılık riskini azaltacağı hipotezi test edilmiştir. Bu amaçla, İA tedavi ile diğer klinik ve radyolojik değişkenlerin hasta sonuçlarına etkisi araştırılmıştır. Univariate analizde milrinon tedavisinin anlamlı olmamakla birlikte bağımlılık riskini azaltma eğiliminde olduğu görülmüştür (OR: 0.94, p = 0.945). Multivariate analizde de benzer bulgular görülmüştür (OR: 0.56, p = 0.594). İAT grubunda mortalitenin anlamlı düzeyde olmayan artış eğilimi dikkat çekmiştir. Multivariate regression analizinde mortalite riskini anlamlı düzeyde arttıran tek faktörün yaş olduğu saptanmıştır. Sonuç olarak, İA milrinon tedavisi güvenli bulunmakla birlikte, GSİ hastalarında uzun dönem sağkalım ve fonksiyonel sonuçlar üzerinde anlamlı bir fayda sağlamamıştır. Bulguların doğrulanması için daha büyük örneklemli, prospektif, çok merkezli çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• milrinon
• geç serebral iskemi
• intraarteriyel tedavi
• anevrizmal subaraknoid kanama
• mikrocerrahi
• endovasküler tedavi

Intraarterial Milrinone Therapy for Delayed Cerebral Ischemia: Impact on Functional Dependency and Mortality

Öz

Delayed cerebral ischemia (DCI) secondary to aneurysmal subarachnoid hemorrhage (aSAH) is a major contributor to morbidity and mortality. In addition to oral nimodipine, normovolemia, and induced hypertension, intra-arterial (IA) administration of vasodilators has been employed in DCI treatment. One such agent is milrinone, a phosphodiesterase-3 inhibitor. This study aimed to evaluate the long-term clinical outcomes of IA milrinone administration. In this retrospective controlled study, 60 patients diagnosed with DCI following aSAH and treated at our institution between January 2023 and June 2024 were analyzed. Of these, 35 received only standard DCI therapy, and 25 underwent IA milrinone administration in addition to standard treatment. No serious or permanent complications related to milrinone administration were observed. Clinical and radiological data were compared, and outcomes were assessed using the modified Rankin scale at 6 months postoperatively. The hypothesis that IA milrinone reduces mortality and functional dependency was tested. The univariate analysis showed a non-significant trend toward reduced dependency in the milrinone group (OR: 0.94, p = 0.945), and similar findings were observed in the multivariate analysis (OR: 0.56, p = 0.594). A nonsignificant increase in mortality was observed in the IA therapy group. Age was the only independent predictor of survival. In conclusion, although IA milrinone therapy appears to be safe, it does not confer a statistically significant benefit in terms of long-term survival or functional outcomes in patients with DCI. Further large-scale prospective multicenter studies are required to validate these findings.

Anahtar Kelimeler

• delayed cerebral ischemia
• aneurysmal subarachnoid hemorrhage
• microsurgery
• endovascular treatment
• milrinone
• intraarterial therapy

Kaynakça

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