What is the effect of Montelukast (leukotriene receptor antagonist) on the brain after a post-aneurysm rupture subarachnoid hemorrhage (SAH) treated with coiling?

Montelukast Has No Established Role in Post-Aneurysmal Subarachnoid Hemorrhage Management After Coiling

There is currently no evidence supporting the use of montelukast (a leukotriene receptor antagonist) for brain protection after aneurysmal subarachnoid hemorrhage (aSAH) treated with coiling.

Current Management Priorities After aSAH and Coiling

Securing the Aneurysm

• Complete obliteration of the aneurysm should be the primary goal whenever feasible to reduce the risk of rebleeding 1
• For posterior circulation aneurysms, coiling is preferred over clipping to improve outcomes 1, 2
• For patients with incomplete obliteration, partial treatment aimed at securing the rupture site during the acute phase is reasonable, with retreatment in 1-3 months 1

Managing Complications

• Delayed cerebral ischemia (DCI) is a major complication after aSAH that can lead to poor outcomes 3
• Management focuses on:
  • Maintenance of euvolemia and normal circulating blood volume 2, 3
  • Induction of hypertension for patients with DCI (unless contraindicated) 2, 3
  • Monitoring for vasospasm using transcranial Doppler 2, 3

Hydrocephalus Management

• Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage) 1
• Chronic symptomatic hydrocephalus requires permanent cerebrospinal fluid diversion 1
• Weaning EVD over >24 hours does not appear to reduce the need for ventricular shunting 1

Seizure Management

• The incidence of seizures after aSAH ranges from 6% to 18% 1
• Risk factors include middle cerebral artery aneurysms, thick SAH clot, intracerebral hematoma, rebleeding, infarction, poor neurological grade, and history of hypertension 1
• Patients treated with endovascular coiling have a lower incidence of seizures compared to surgical clipping 1

Vasospasm and Treatment Modality

• Coiling is associated with significantly lower rates of vasospasm (38%) compared to clipping (60%) 4
• Delayed cerebral infarction is also less common after coiling (6%) than after clipping (17%) 4
• Clinical deterioration due to delayed cerebral ischemia tends to be lower with coiling (6%) compared to clipping (16%) 4

Absence of Evidence for Montelukast

• Current American Heart Association/American Stroke Association guidelines for aSAH management do not mention montelukast or other leukotriene receptor antagonists as treatment options 1
• The guidelines focus on established treatments for preventing complications after aSAH, including maintenance of euvolemia, induced hypertension for DCI, and monitoring for vasospasm 2
• No clinical studies have evaluated the efficacy of montelukast specifically in the context of post-aSAH brain protection after coiling

Established Treatments for Vasospasm and DCI

• Hemodynamic augmentation with induced hypertension with or without inotropic support is the first-line treatment for DCI 3
• For patients who don't respond to or cannot tolerate hemodynamic augmentation, endovascular therapy (intraarterial vasodilators and balloon angioplasty) is a complementary strategy 3
• Some experimental treatments have been studied, such as intrathecal sodium nitroprusside, which has shown promise in reversing severe vasospasm in small case series 5
• Blood volume expansion and/or induced hypertension, along with pharmacological control of increased intracranial pressure, currently provide the best basis for clinical management of cerebral ischemic complications of SAH 6

Conclusion

Based on current evidence and guidelines, there is no established role for montelukast in the management of patients after aneurysmal subarachnoid hemorrhage treated with coiling. Management should focus on established strategies for preventing and treating complications such as vasospasm and delayed cerebral ischemia.