Intra-Arterial Dantrolene for Refractory Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Dantrolene has a safe side-effect profile and a mechanism of action that makes it attractive as an option for treatment of cerebral vasospasm. The authors report 2 cases of refractory cerebral vasospasm secondary to aneurysmal subarachnoid hemorrhage that were successfully treated with intra-arterial (IA) dantrolene. CASE DESCRIPTION: Two patients, a 63-year-old woman and 36-year-old woman, developed severe vasospasm refractory to IA vasodilators after rupture of anterior communicating artery aneurysms. IA dantrolene was injected in doses of 15-30 mg in the affected distributions and mean arterial pressure, intracranial pressure, and heart rate were monitored. There was immediate improvement in lumen diameter of the affected vessels following dantrolene injection. No significant differences in mean arterial pressure or intracranial pressure before and after IA dantrolene were observed. Both patients demonstrated clinical improvement within 24 hours without any further deterioration during the rest of their admission. Follow-up angiography 48 hours after IA dantrolene treatment demonstrated continued resolution of cerebral vasospasm. CONCLUSIONS: This evidence suggests IA dantrolene as a safe and effective novel alternative for the treatment of cerebral vasospasm.

Middle Cranial Fossa Approach to Repair Tegmen Defects with Autologous or Alloplastic Graft.

BACKGROUND: Temporal bone tegmen defects may be associated with cerebrospinal fluid (CSF) otorrhea. A variety of techniques have been used for repair. We report our experience with skull base reconstruction for tegmen defects using either autologous or alloplastic grafts. METHODS: A retrospective chart review was performed on patients with tegmen defects treated from 2007 to 2017 at the University Hospital in Columbia, Missouri, USA. Primary outcome measures were analyzed. RESULTS: Twenty-five patients were treated with a middle cranial fossa approach (median age 53, 88% females, median body mass index 34, median follow-up 9 months). Presenting symptoms included CSF leak (92%), hearing loss (44%), imbalance (12%), meningitis (12%), headache (4%), and tinnitus (4%). Most tegmen defects occurred spontaneously (84%) but cholesteatomas (4%), and trauma (12%) also were identified. Pre- and postoperative audiograms were available for 13 patients (52%); 7 (54%) showed objective improvement. Fourteen patients were repaired with autologous bone graft (56%), 7 with alloplastic grafts (28%), and 4 with temporalis fascia only (16%). All patients had resolution of CSF leak. Two patients (8%) suffered wound infections and 3 (12%) had facial and/or petrosal nerve complications. Use of alloplastic graft significantly shortened operative time (allopathic mean 180 minutes vs. autologous mean 208 minutes; P = 0.03). CONCLUSIONS: CSF otorrhea due to tegmen defects can be repaired via a middle fossa craniotomy using either an autologous or alloplastic graft with equivalent outcomes and efficacy, although alloplastic graft helps reduce operating time.