A new lifeline for little brains: safe and effective intrathecal nicardipine use for refractory vasospasm in paediatric aneurysmal subarachnoid haemorrhage

We present a case of aneurysmal subarachnoid haemorrhage in a preadolescent teenage patient from a right posterior inferior cerebellar artery origin aneurysm rupture. During coiling they had a re-rupture event with cerebral anoxia which necessitated decompressive craniectomy on bleed day three due to medically refractory intracranial hypertension. The patient then developed severe bilateral V4 and basilar vasospasm. In addition to blood pressure control and fluids, 4mg of intrathecal nicardipine was administered every eight hours into the ventriculostomy for 5 days. Vasospasm was markedly improved within 24 hours and resolved within two days. MRI did not show any focal vasospasm-related stroke. At 6-month follow up, the only neurological deficit was short-term memory loss. The outcome of this case highlights the potential for IT nicardipine to safely and effectively reduce paediatric vasospasm and avoid detrimental injury resulting from cerebral ischemia.