Citation Information :
Banerjee R, Goswami L, Rout D, Ramasubban S, Sharma J. Methylene Blue to the Rescue in Severe Vasoplegia after Oral Nimodipine in a Patient with Aneurysmal Subarachnoid Hemorrhage. 2023; 2 (3):75-77.
Aim and background: We report the first case in India of refractory vasoplegia from oral nimodipine after aneurysmal subarachnoid hemorrhage (aSAH) and its successful rescue with intravenous methylene blue.
Case description: A 53-year-old man presented with fever, headache, and neck pain from SAH due to the rupture of a suspected mycotic aneurysm. He was on peroral nimodipine postcoiling. After 1 hour, he developed severe hypotension, unresponsive to triple vasopressors. His low diastolic pressure pointed toward vasoplegia and after ruling out other causes with point-of-care ultrasound (POCUS), 200 mg of methylene blue was administered intravenously. The vasopressor requirement decreased immediately. No side effects were observed except chromaturia.
Conclusion: Nimodipine is recommended orally to reduce unfavorable outcomes from delayed cerebral ischemia. Mild hypotension is common, but in rare cases, it may lead to profound refractory vasoplegia. This case demonstrates the successful use of methylene blue as a potential rescue therapy.
Omar S, Zedan A, Nugent K. Cardiac vasoplegia syndrome: pathophysiology, risk factors and treatment. Am J Med Sci 2015;349(1):80–88. DOI: 10.1097/MAJ.0000000000000341
Diringer MN, Bleck TP, Claude Hemphill J 3rd, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care 2011;15(2):211–240. DOI: 10.1007/s12028-011-9605-9
Bele S, Scheitzach J, Kieninger M, et al. Vasoplegic syndrome after oral nimodipine application in patients with subarachnoid hemorrhage. J Anaesth Crit Care Open Access 2014;1(6):00035. DOI: 10.15406/jaccoa.2014.01.00035
Macdonald RL, Hunsche E, Schüler R, et al. Quality of life and healthcare resource use associated with angiographic vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 2012;43(4): 1082–1088. DOI: 10.1161/STROKEAHA.111.634071
Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial. BMJ 1989;298(6674):636–642. DOI: 10.1136/bmj.298.6674.636
Wessell A, Kole MJ, Badjatia N, et al. High compliance with scheduled nimodipine is associated with better outcome in aneurysmal subarachnoid hemorrhage patients cotreated with heparin infusion. Front Neurol 2017;8:268. DOI: 10.3389/fneur.2017.00268
Busse LW, Barker N, Petersen C. Vasoplegic syndrome following cardiothoracic surgery—review of pathophysiology and update of treatment options. Crit Care 2020;24(1):36. DOI: 10.1186/s13054-020-2743-8
Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. Interv Neurol 2013;2(1): 30–51. DOI: 10.1159/000354755
Mekontso-Dessap A, Houël R, Soustelle C, et al. Risk factors for post-cardiopulmonary bypass vasoplegia in patients with preserved left ventricular function. Ann Thorac Surg 2001;71(5):1428–1432. DOI: 10.1016/s0003-4975(01)02486-9
Cremer J, Martin M, Redl H, et al. Systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg 1996;61(6): 1714–1720. DOI: 10.1016/0003-4975(96)00055-0
Beasley D, McGuiggin M. Interleukin 1 activates soluble guanylate cyclase in human vascular smooth muscle cells through a novel nitric oxide-independent pathway. J Exp Med 1994;179(1):71–80. DOI: 10.1084/jem.179.1.71
Bele S, Schebesch KM, Scheitzach J, et al. Vasopressin increases cerebral perfusion pressure but not cerebral blood flow in neurosurgical patients with catecholamine-refractory hypotension: a preliminary evaluation using the non-invasive quantix nd in comparison to the literature. J Anaesth Crit Care Open Access 2014;1(3):00017. DOI: http://dx.doi.org/10.15406/jaccoa.2014.01.00017
