What is the recommended dose of nimodipine (calcium channel blocker) for the management of intracranial hemorrhage (ICH)?

Nimodipine Dosing for Intracranial Hemorrhage

Nimodipine is not indicated for primary intracerebral hemorrhage (ICH), but is specifically indicated for aneurysmal subarachnoid hemorrhage (SAH) at a dose of 60 mg orally every 4 hours for 21 consecutive days starting within 96 hours of onset.

Correct Indication and Dosing

• Nimodipine is only FDA-approved for use in subarachnoid hemorrhage, not primary intracerebral hemorrhage 1
• For aneurysmal SAH, the recommended dosing is:
  • 60 mg (two 30 mg capsules) orally every 4 hours
  • Continue for 21 consecutive days
  • Start within 96 hours of SAH onset 2, 1
• Administration route:
  • Oral administration only
  • For patients who cannot swallow, capsules can be punctured with an 18-gauge needle and contents extracted into an oral syringe (clearly labeled "Not for IV Use")
  • Contents can be administered via nasogastric tube or PEG tube 1

Important Safety Considerations

• NEVER administer nimodipine intravenously or by other parenteral routes as this can cause severe hypotension requiring cardiovascular support 1
• Dose adjustments:
  • For patients with liver dysfunction or cirrhosis: reduce to 30 mg every 4 hours 1
  • Elderly patients may require dose reduction due to approximately 2× higher plasma concentrations 2
• Monitor for hypotension, which is a common side effect:
  • Up to 78% of SAH patients develop systemic hypotension at standard doses 3
  • Hypotension may require dose reduction or discontinuation 4

Evidence for Efficacy

• Nimodipine reduces the severity of neurological deficits resulting from vasospasm in SAH patients 1
• It decreases the incidence of cerebral infarction by 34% and unfavorable outcomes by 40% 2
• Multiple randomized controlled trials have shown that nimodipine improves outcomes in SAH patients 1

Lack of Evidence for ICH

• There are no guidelines recommending nimodipine for primary intracerebral hemorrhage 5
• The European Stroke Organisation guidelines for ICH management do not include nimodipine as a recommended treatment 5
• The Neurocritical Care Society guidelines for reversal of antithrombotics in ICH do not mention nimodipine 5

Clinical Pearls

• Avoid grapefruit juice during treatment as it affects metabolism 2
• Maintain euvolemia rather than hypervolemia or hypovolemia 2
• In practice, many patients do not complete the full 21-day course due to hypotension or early discharge 4
• For patients with SAH and vasospasm despite standard dosing, some evidence suggests that higher doses (4 mg/hr IV) may be effective when guided by transcranial Doppler, but this is not standard practice 6

In summary, nimodipine has no established role in the management of primary intracerebral hemorrhage. Its use should be restricted to aneurysmal subarachnoid hemorrhage at the recommended dose of 60 mg orally every 4 hours for 21 days.