Terapia continua intra-arterial selectiva con nimodipino para el tratamiento del vasoespasmo refractario en hemorragia subaracnoidea aneurismática: caso clínico / Continuous intra arterial nimodipine for vasospasm secondary to subarachnoid hemorrhage: report of one case

We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential.

[Continuous intra arterial nimodipine for vasospasm secondary to subarachnoid hemorrhage. Report of one case]. / Terapia continua intra-arterial selectiva con nimodipino para el tratamiento del vasoespasmo refractario en hemorragia subaracnoidea aneurismática. Caso clínico.

We report a 39-year-old male with an aneurysmal subarachnoid hemorrhage without hydrocephalus, in whom a right choroidal aneurysm was early excluded by endovascular coil insertion. Intracranial pressure (PIC) and cerebral oxygenation (PtiO2) sensors for neuromonitoring were installed due to a persistent comatose state. From the 3rd day, neuromonitoring became altered. CT angiography and cerebral angiography showed severe proximal and distal vasospasm (VE) of the middle (ACM) and anterior (ACA) right cerebral arteries. VE was treated with angioplasty and intravenous nimodipine. Forty eight hours later, despite hemodynamic maximization, neuromonitoring became altered again, mainly explained by a decrease in PtiO2 below 15 mmHg. A severe VE in ACM and right ACA was confirmed by angiography. Given the presence of an early and recurrent VE, which was associated with a decrease in cerebral oxygenation, internal carotid micro-catheters for continuous nimodipine infusion were installed. This therapy maintained a normal neuromonitoring for 15 days. During this period, attempts were done to decrease or discontinue the infusion, but the patient presented parallel falls of cerebral oxygenation or decreased cerebral perfusion observed with perfusion CT, interpreted as persistent VE. Finally, the infusion was stopped at day 15 without significant complication. We conclude that intra-arterial nimodipine continuous infusion in refractory VE can be useful and safe in selected patients. Multimodal neuromonitoring is essential.

Más allá del sodio: cambios en la dieta y su efecto en hipertensión / Beyond sodium: diet changes and their effect on hypertension

Resumen: La hipertensión arterial (HTA) es un importante factor de riesgo cardiovascular y su prevalencia aumenta con la edad, dado el aumento de la expectativa de vida de nuestra población esta condición constituye una prioridad a nivel de salud pública. Tanto para el tratamiento como para la prevención de la HTA son importantes las medidas no farmacológicas como cambios en el estilo de vida y especialmente la alimentación. Además de la restricción de sodio, existen otras medias dietéticas que han demostrado estar asociadas con un mejor control de la HTA en diversos ensayos clínicos, tales como la reducción del peso corporal, la dieta rica en frutas y verduras, el mayor consumo de potasio y magnesio, la vitamina D, los ácidos grasos ome-ga-3, los flavonoides y la disminución de la ingesta de sacarosa, fructosa, cafeína y alcohol. Dado la gran prevalencia de HTA en nuestro país del orden de un 26,9 por ciento, es importante dar a conocer medidas dietéticas que nos permitirán un mejor control de la presión en pacientes hipertensos y un retraso de la aparición de esta enfermedad en sujetos sanos, además de su incorporación en campañas de educación nutricional poblacional por parte de las autoridades sanitarias.

Hypertension is an important cardiovascular risk factor and its prevalence increases with age. Given the rising life expectancy in Chile, the prevention of hypertension is a priority for public health policies. Non pharmacological therapies, such as life style and diet changes are especially important. In addition to sodium restriction, several clinical studies have shown that other dietary interventions, such as an increased fruit and vegetable content of diet, higher intake of potassium and magnesium, vitamin D, omega-3 fatty acids, flavonoids, decreased intake of sucrose, fructose, caffeine and alcohol, lead to better control of hypertension. Given de high prevalence of hypertension in Chile (26.9 per cent overall) better information about the benefits of diet changes might be very important in order to help prevent and delay the appearance of hypertension. Appropriate public educational policies should be implemented by the sanitary authorities.