Beyond Vasospasm: Dual Milrinone and Balloon Angioplasty in Refractory Delayed Cerebral Ischemia Post-Subarachnoid Hemorrhage.

Cerebral vasospasm is a major complication of aneurysmal subarachnoid hemorrhage and a key contributor to delayed cerebral ischemia, which remains a leading cause of morbidity despite standard therapy with nimodipine and induced hypertension. Up to 30% of patients develop refractory delayed cerebral ischemia, highlighting the need for alternative therapeutic strategies. Milrinone has emerged as a promising option due to its combined vasodilatory and inotropic properties. We report the case of a 42-year-old man who developed progressive neurological deterioration following aneurysmal subarachnoid hemorrhage secondary to rupture of an anterior cerebral artery aneurysm. Despite definitive microsurgical clipping and optimal standard management, the patient developed refractory delayed cerebral ischemia with severe vasospasm. A stepwise, physiology-guided treatment strategy was implemented, including high-dose intravenous milrinone infusion, intra-arterial milrinone administration, and rescue balloon angioplasty. This approach resulted in significant angiographic improvement, progressive neurological recovery, and successful ventilatory weaning. This case highlights the value of a multimodal, escalation-based strategy for the management of refractory delayed cerebral ischemia, supporting the use of milrinone as a potential first-line rescue therapy and reserving balloon angioplasty for non-responders. It reinforces the concept of delayed cerebral ischemia as a multifactorial process and underscores the critical role of intensive neuromonitoring in enabling safe and effective therapeutic escalation.