Utilidad de la milrinona en el tratamiento del vasoespasmo cerebral secundario a la hemorragia subaracnoidea aneurismática: revisión narrativa

OBJECTIVE: To review and summarize the available clinical evidence on the use of milrinone in aneurysmal subarachnoid hemorrhage (aSAH), focusing on its efficacy in the prevention and treatment of cerebral vasospasm and delayed cerebral ischemia (DCI). METHOD: A narrative review of the literature was conducted using PubMed, EMBASE, ScienceDirect, and The Cochrane Database, without restrictions on publication date. The search included the following terms: milrinone, vasospasm, delayed cerebral ischemia, and subarachnoid hemorrhage. The last bibliographic search was performed in June 2025. Studies of any methodological design were considered, including randomized clinical trials, observational studies, case series, and case reports, provided they addressed the use of milrinone in this clinical context. RESULTS: A total of 28 studies were identified, of which 21 were included in the final analysis. Most studies were observational and heterogeneous in design. Overall, intravenous and intra-arterial milrinone administration was consistently associated with angiographic improvement of cerebral vasospasm and favorable effects on cerebral hemodynamics, as well as a reduction in the need for rescue endovascular therapies. However, evidence regarding a consistent benefit on functional outcomes and mortality remains limited. Hypotension and electrolyte disturbances were the most frequently reported adverse events, although serious cardiovascular complications were uncommon. Only one randomized clinical trial comparing milrinone with magnesium sulfate showed no superiority of milrinone in preventing vasospasm and reported a higher incidence of hypotension. CONCLUSIONS: Milrinone appears to be a potentially useful therapeutic option for the management of cerebral vasospasm and DCI after aSAH, particularly as a rescue therapy. Nevertheless, the current evidence is largely based on non-randomized studies and does not provide definitive proof of consistent functional benefit. Ongoing and recently completed randomized clinical trials may help clarify its efficacy and safety profile and define its role in clinical practice.