Continuous Intra-arterial Nimodipine Infusion as a Treatment for Severe Cerebral Vasospasm Following Microsurgical Resection of a Sphenoid Wing Meningioma

Cerebral vasospasm is a rare complication of intracranial tumor surgery that, unfortunately, is often diagnosed late with devastating consequences for the patient. It usually presents as a delayed neurological deficit after the first week of the postoperative period, and the associated morbidity and mortality rates reach 50% and 30%, respectively. Despite the relative paucity of evidence, some possible risk factors have been suggested, such as sellar or middle fossa tumor locations, vascular encasement or stenosis by the tumor, significant surgical vessel manipulation, and postoperative subarachnoid hemorrhage. A 40-year-old patient who had recently undergone resection of a left sphenoid wing meningioma was readmitted 8 days after surgery for sensorimotor aphasia. A small hemorrhage was noted in the surgical cavity, and progressive swelling was reported in the left middle cerebral artery’s (MCA) territory. Initially, the deficit was suspected to be caused by perilesional edema or epileptic activity; however, after the patient’s deficit worsened despite medical treatment, computed tomography angiography and perfusion performed 6 days after readmission revealed severe vasospasm with hemodynamic compromise in the inferior trunk of the left MCA, which was later confirmed by cerebral angiography. Endovascular treatment with intra-arterial milrinone injection was performed with unsatisfactory results. Therefore, continuous local intra-arterial nimodipine administration (CLINA) was initiated, which helped to gradually restore the vessel diameter, reduce the mass effect, and normalize the perfusion in the affected vascular territory. Despite a positive radiological outcome, the patient was discharged with transcortical sensory aphasia, which partially improved in the following months. We present a case of delayed severe vasospasm after skull base tumor surgery to emphasize the importance of early recognition, the need for a high index of suspicion when associated factors are involved, and to introduce CLINA as a new endovascular approach to treat this rare complication.