Sigismond Lasocki

Introduction: Blood pressure (BP) variability, particularly arterial hypotension during mechanical thrombectomy (MT) for acute ischemic stroke (AIS), has been associated with unfavorable outcomes. This variability in BP is notably present during induction in general anesthesia (GA). This study seeks to assess the effectiveness of a personalized BP management protocol during MT under general GA in mitigating hypotension and its impact on functional outcomes at 90 days. Methods: We conducted a monocentric before-after study involving two retrospective cohorts of patients who underwent MT for AIS under GA, before and after implementing the protocol. The protocol aimed to maintain the mean arterial pressure (MAP) within 10% of the baseline MAP prior to induction. The main outcome measured was the modified Rankin Scale (mRS) at 90 days. Results: Our analysis included 179 patients: 121 before and 58 after protocol implementation. The “after” group showed a reduced proportion of MAP drops, especially severe hypotension (32.8% vs. 48.8% below 30% from baseline, and 51.7% vs. 66.1% below 20%). However, these differences lacked statistical significance. At 90 days, a poor outcome (mRS > 2) was observed in 56.9% of patients in the ‘after’ group vs. 46.3% in the ‘before’ group, not statistically significant. This association remained statistically insignificant in both univariate and multivariate analyses. Conclusion: The personalized BP management during MT resulted in a decrease in BP drops without reaching significance. Furthermore, this study did not indicate any improvement in neurological outcomes at 90 days.

Introduction Subarachnoid haemorrhage (SAH) is relatively frequent, accounting for 5% of strokes and affects a young population. Arterial vasospasm is a frequent complication of SAH, with an estimated incidence as high as 70%. Vasospasm is responsible for cerebral ischaemia which in turn is potentially responsible for severe morbidity (neurological deficit, neuropsychiatric disorders), poor quality of life (institutionalisation, inability to return to work) and increased mortality. Treatment with intravenous milrinone, an arterial vasodilator, has been proposed, but no randomised controlled study exists. We hypothesised that an intravenous infusion of milrinone would improve the neurological recovery of patients with vasospasm following aneurysmal SAH at 3 months. Methods and analysis The MiVAR (Milrinone Infusion for VAsospam treatment in subarachnoid hemoRrhage) study is an investigator-initiated, phase III multicentre, randomised placebo-controlled, double-blinded, superiority trial evaluating the effect of intravenous milrinone versus placebo (saline), in patients with cerebral vasospasm following aneurysmal SAH. Patients will be included within 6 hours of the confirmation of vasospasm diagnosis by a CT angiography and randomised to receive either milrinone (initial bolus of 0.1 mg/kg over 30 min—max 10 mg—followed by a continuous infusion at 1 µg/kg/min rate for at least 48 hours) or placebo. Milrinone (or placebo) could be increased to 1.5 µg/kg/min. The dose is adapted according to the clinical and/or transcranial Doppler response. 360 patients are expected to be included. The primary endpoint is the proportion of patients with a good neurological outcome at 3 months, defined as a modified Rankin score ≤2, obtained through a centralised standardised telephone interview (done by a unique trained team). The study started in August 2020, and the expected final follow-up is the last quarter of 2025. Analyses of the intention-to-treat and per-protocol populations are planned. Ethics and dissemination The MiVAR trial protocol has been approved by an ethics committee (Comité de Protection des Personnes Ouest V), by the Agence Nationale de Sécurité du Médicament (ANSM, Number 160 828A-21, approval date 26 December 2019) and by the ‘Commission Nationale Informatique et Liberté’ (CNIL, decision DR-2020-076, approval date 21 February 2020). The study will be conducted according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The MiVAR study will be the first multicentre randomised study to evaluate the efficacy of intravenous milrinone in improving the neurological outcomes at 3 months in patients with vasospasm following aneurysmal SAH. Trial registration numbers NCT04362527, EudractCT number 2019-002145-37.