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Paľa A, Schneider M, Brand C, Pedro MT, Özpeynirci Y, Schmitz B, Wirtz CR, Kapapa T, König R, Braun M. The evolution of invasive cerebral vasospasm treatment in patients with spontaneous subarachnoid hemorrhage and delayed cerebral ischemia—continuous selective intracarotid nimodipine therapy in awake patients without sedation. Neurosurg Rev 2018; 42:463-469. [DOI: 10.1007/s10143-018-0986-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/01/2018] [Accepted: 05/17/2018] [Indexed: 11/30/2022]
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Bashir A, Andresen M, Bartek J, Cortsen M, Eskesen V, Wagner A. Intra-arterial nimodipine for cerebral vasospasm after subarachnoid haemorrhage: Influence on clinical course and predictors of clinical outcome. Neuroradiol J 2016; 29:72-81. [PMID: 26825134 DOI: 10.1177/1971400915626429] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Intra-arterial nimodipine (IAN) has shown a promising effect on cerebral vasospasm (CV) after aneurysmal subarachnoid haemorrhage. At our institution, Rigshospitalet, IAN treatment has been used since 2009, but the short- and long-term clinical efficacy of IAN has not yet been assessed. The purpose was to evaluate the efficacy and clinical outcome of IAN treatment of symptomatic CV, and to assess the predictors of clinical outcome. Medical records of 25 patients undergoing a total of 41 IAN treatment sessions were retrospectively reviewed. Data on angiographic results, blood-flow velocities and the clinical condition before and after the IAN treatment were recorded. Predictors of the clinical outcome were assessed with a linear regression model. Positive angiographic response was achieved in 95.1% of 41 IAN treatment sessions. Flow-velocity measurements showed no relationship with angiographic responses of IAN. The immediate clinical improvement was observed in three patients (12%). Five patients (20%) had a favourable outcome at discharge and at three-month follow-up; 10 patients (40%) had a moderate to poor outcome; and the rest (40%) died. Increased number of affected vessels and number of procedures carried out per patient, and a trend toward an increased delay time from symptomatic CV to confirming angiographic CV and thus instituting IAN treatment predicted the poor clinical outcome. IAN treatment appears to be effective in reversing angiographic CV. However, it is not always effective in reversing clinical deterioration, as several other factors including treatment delay affect the clinical course.
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Affiliation(s)
- Asma Bashir
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jiri Bartek
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska Institutet and Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Cortsen
- Department of Radiology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Aase Wagner
- Department of Radiology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Baltsavias G, Yella S, Al Shameri RA, Luft A, Valavanis A. Intra-arterial administration of papaverine during mechanical thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2014; 24:41-7. [PMID: 25440359 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 07/13/2014] [Accepted: 07/27/2014] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND The use of stent retrievers for mechanical thrombectomy in acute ischemic stroke may induce significant vasospasm, which at the early phases of reperfusion may be crucial for rethrombosis of the recanalized vessel. We aimed to study whether the use of intra-arterial papaverine in selected cases of vasospasm was associated with improved cerebral perfusion, arterial reocclusion, or increased hemorrhagic complications. METHODS We retrospectively studied 9 consecutive patients with large artery acute occlusion, treated with stent retriever and intra-arterial papaverine. Onset to administration of intravenous recombinant tissue-plasminogen activator time, baseline National Institute of Health Stroke Scale, time to reperfusion, number of passes of the stent retriever, modified Rankin Scale score at discharge, postprocedural hemorrhage, onset to reperfusion time, papaverine dose, and thrombolysis in cerebral infarction grade were recorded in all patients. RESULTS After papaverine administration, the caliber of the infused arteries and their flow was increased in all cases. In none of the treated cases a reocclusion occurred after papaverine infusion. In one of the studied patients (11%), a parenchymal bleeding occurred 36 hours postoperatively. CONCLUSIONS This small study suggests that intra-arterial infusion of papaverine for the treatment of cerebral vasospasm after mechanical thrombectomy in acute ischemic stroke is effective and safe.
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Affiliation(s)
| | - Susmitha Yella
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Anton Valavanis
- Department of Neuroradiology, University Hospital Zurich, Zurich, Switzerland
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Kerz T, Boor S, Beyer C, Welschehold S, Schuessler A, Oertel J. Effect of intraarterial papaverine or nimodipine on vessel diameter in patients with cerebral vasospasm after subarachnoid hemorrhage. Br J Neurosurg 2012; 26:517-24. [DOI: 10.3109/02688697.2011.650737] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Musahl C, Henkes H, Vajda Z, Coburger J, Hopf N. Continuous Local Intra-arterial Nimodipine Administration in Severe Symptomatic Vasospasm After Subarachnoid Hemorrhage. Neurosurgery 2011; 68:1541-7; discussion 1547. [DOI: 10.1227/neu.0b013e31820edd46] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Cerebral vasospasm (CV) is a potentially disastrous consequence of subarachnoid hemorrhage despite medical treatment. Nimodipine is a potent drug for vessel relaxation, but side effects may preclude a sufficient dose.
OBJECTIVE:
To explore whether continuous local intra-arterial nimodipine administration (CLINA) can reverse vasospasm and prevent delayed ischemic neurological deficit.
METHODS:
Six consecutive subarachnoid hemorrhage patients (5 women; mean age, 47.2 years) with severe CV despite maximum medical therapy underwent CLINA within 2 hours after the onset of clinical symptoms. After anticoagulation, microcatheters were inserted distally in the concerning supra-aortic vessels. Glyceryl trinitrate injection (2 mg) was followed by CLINA (nimodipine 0.4 mg/h for 70-147 hours). Duration of CLINA was determined by neurological status, transcranial Doppler sonography, and partial tissue oxygen pressure values.
RESULTS:
In all patients, neurological deficits improved or partial tissue oxygen pressure values returned to normal and transcranial Doppler sonography confirmed a reduced blood flow velocity within 12 hours. Magnetic resonance imaging showed no ischemic lesion caused by CV. Neurological outcome was good (modified Rankin Scale score, 0–2) in 3 patients, whereas 1 patient had a moderate clinical outcome (modified Rankin Scale score, 3–4) and 2 patients had a poor outcome (modified Rankin Scale score, 5) because of the SAH.
CONCLUSION:
Preliminary data show that CLINA is a straightforward, effective, and safe option for patients with severe CV refractory to medical therapy. Dilation of spastic arteries starts within a few hours and is lasting. Indication for CLINA is peripheral and diffuse CV at any location.
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Affiliation(s)
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Germany
- Medizinische Fakultät der Universität Duisburg-Essen
| | - Zsolt Vajda
- Department of Neuroradiology, Klinikum Stuttgart, Germany
| | - Jan Coburger
- Department of Neurosurgery, Klinikum Stuttgart, Germany
| | - Nikolai Hopf
- Department of Neurosurgery, Klinikum Stuttgart, Germany
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Srivastava VK, Agrawal S, Sahu S. Association of acute onset hypertension and tachycardia following intracisternal papaverine administration during intracranial aneurysm surgery: a case report and review of the literature. J Clin Anesth 2011; 23:224-6. [DOI: 10.1016/j.jclinane.2010.01.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Revised: 01/01/2010] [Accepted: 01/08/2010] [Indexed: 11/30/2022]
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Baltaci B, Basar H, Ozcan A, Gulhan Y, Aytunur CS. Cardiac arrest after intracisternal papaverine instillation during intracranial aneurysm surgery. Case report. J Neurosurg 2010; 113:760-2. [PMID: 19961315 DOI: 10.3171/2009.11.jns09899] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage is still a leading cause of morbidity and death. This 50-year-old man underwent surgery for aneurysm clipping. After the aneurysm was clipped, papaverine was instilled into the surgical area. Bradycardia, hypotension, and sinus arrest developed in the first minute after applying the papaverine. Thus, the authors concluded that the application of papaverine to the surgical area can result in fatal bradycardia and hypotension.
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Affiliation(s)
- Bulent Baltaci
- Department of Anaesthesiology and Reanimation, Ankara Training and Research Hospital, Ministry of Health, Ankara, Turkey
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Sommer CM, Radeleff BA. A novel approach for percutaneous treatment of massive nonocclusive mesenteric ischemia: tolazoline and glycerol trinitrate as effective local vasodilators. Catheter Cardiovasc Interv 2009; 73:152-5. [PMID: 19156878 DOI: 10.1002/ccd.21811] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nonocclusive mesenteric ischemia (NOMI) generally affects patients with low cardiac output, resulting in splanchnic hypoperfusion. It includes all forms of mesenteric ischemia without vessel occlusion and makes up between 20 and 30% of all cases of acute mesenteric ischemia. We present the case of a 84-year-old man with a history of total atrioventricular block developing NOMI. This was diagnosed by percutaneous selective catheter arteriography (PSCA), which demonstrated remarkable abrupt termination of the jejunal vasculature and multiple severe spasms of the colonic arteries. Control PSCA after local intraarterial vasodilator therapy (LIVT) with tolazoline and glycerol trinitrate documented an excellent therapeutic result with a completely unremarkable vasculature. Although LIVT was complicated by severe cardiovascular complications inclusive of cardiac arrest with the need of cardiopulmonary resuscitation, the patient fully recovered and was discharged after implantation of a cardiac pacemaker in good clinical condition 7 days later.
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Abstract
The major efforts to selectively deliver drugs to the brain in the past decade have relied on smart molecular techniques to penetrate the blood-brain barrier, whereas intraarterial drug delivery has drawn relatively little attention. Meanwhile, rapid progress has been made in the field of endovascular surgery. Modern endovascular procedures can permit highly targeted drug delivery by the intracarotid route. Intracarotid drug delivery can be the primary route of drug delivery or it could be used to facilitate the delivery of smart neuropharmaceuticals. There have been few attempts to systematically understand the kinetics of intracarotid drugs. Anecdotal data suggest that intracarotid drug delivery is effective in the treatment of cerebral vasospasm, thromboembolic strokes, and neoplasms. Neuroanesthesiologists are frequently involved in the care of such high-risk patients. Therefore, it is necessary to understand the applications of intracarotid drug delivery and the unusual kinetics of intracarotid drugs.
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Affiliation(s)
- Shailendra Joshi
- Department of Anesthesiology, PH 505, College of Physicians and Surgeons of Columbia University, 630 West 168th Street, New York, New York 10032, USA.
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Adverse effects of topical papaverine on auditory nerve function. Acta Neurochir (Wien) 2008; 150:901-9; discussion 909. [PMID: 18726058 DOI: 10.1007/s00701-008-0004-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 12/27/2007] [Indexed: 10/21/2022]
Abstract
BACKGROUND Papaverine hydrochloride is a direct-acting vasodilator used to manage vasospasm during various neurosurgical operations. Transient cranial nerve dysfunction has been described in a few cases with topical papaverine. This study supports previous reports and provides neurophysiological evidence of an adverse effect on the auditory nerve. METHODS We conducted a retrospective review of 70 consecutive microvascular decompression operations and studied those patients who received topical papaverine for vasospasm. Topical papaverine was used as a direct therapeutic action to manage vasospasm in a total of 11 patients. The timing of papaverine application and ongoing operative events was reviewed relative to changes in neurophysiological recordings. Brainstem auditory evoked potentials (BAEPs) were routinely used to monitor cochlear nerve function during these operations. FINDINGS A temporal relationship was found between topical papaverine and BAEP changes leading to complete waveform loss. The average temporal delay between papaverine and the onset of an adverse BAEP change was 5 min. In 10 of 11 patients, BAEP waves II/III-V completely disappeared within 2 to 25 min after papaverine. Eight of these 10 patients had complete loss of BAEP waveforms within 10 min. One patient showed no recovery of later waves and a delayed profound sensorineural hearing loss. The average recovery time of BAEP waveforms to pre-papaverine baseline values was 39 min. CONCLUSIONS Topical papaverine for the treatment of vasospasm was associated with the onset of a transient disturbance in neurophysiological function of the ascending auditory brainstem pathway. The complete disappearance of BAEP waveforms with a consistent temporal delay suggests a possible adverse effect on the proximal eighth nerve. Recommendations to avoid potential cranial nerve deficits from papaverine are provided.
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Rath GP, Prabhakar H, Dash HH, Suri A. Haemodynamic changes after intracisternal papaverine instillation during intracranial aneurysmal surgery. Br J Anaesth 2006; 97:848-50. [PMID: 16984954 DOI: 10.1093/bja/ael248] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cerebral vasospasm remains a significant cause of mortality and morbidity after aneurysmal subarachnoid haemorrhage. Use of either intra-arterial or intracisternal papaverine as an alternative treatment of refractory cerebral vasospasm has been associated with various complications including haemodynamic instabilities. However, our search in literature did not reveal association of bradycardia and hypotension with the use of papaverine by either of these routes. Here, we describe a case of anterior communicating artery aneurysm with hydrocephalus. The patient underwent craniotomy and clipping of the aneurysm followed by third ventriculostomy. Instillation of papaverine at the surgical site caused significant haemodynamic changes possibly because of stimulation of hypothalamus in the third ventricle or vagal nuclei in the fourth ventricle, or even both. We recommend cautious use of intracisternal papaverine in such scenario especially when third ventriculostomy has been performed as an adjunct surgical procedure.
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Affiliation(s)
- G P Rath
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
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Liu-Deryke X, Rhoney DH. Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage: An Overview of Pharmacologic Management. Pharmacotherapy 2006; 26:182-203. [PMID: 16466324 DOI: 10.1592/phco.26.2.182] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Cerebral vasospasm remains one of the leading causes of mortality in patients who experience a subarachnoid hemorrhage but survive the initial 24 hours. Vasospasm generally occurs 3-4 days after the initial subarachnoid hemorrhage and peaks at 5-7 days. The pathophysiology of vasospasm is poorly understood, which directly contributes to the inconsistency of management and creates a formidable challenge in clinical practice. Traditionally, hemodilution, hypervolemia, and induced hypertension (so-called triple H therapy); calcium channel blockers; and endovascular therapy have been used as either prophylactic therapy or treatment. However, management of vasospasm varies among physicians and institutions mainly because of a lack of large clinical trials and inconsistent results. Practice has been based primarily on case reports and the preference of each practitioner. Several experimental therapies have been explored; however, large, prospective, randomized controlled trials are needed to elucidate the role of these therapies.
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Affiliation(s)
- Xi Liu-Deryke
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan 48201, USA
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13
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Suzuki S, Ito O, Sayama T, Yamaguchi S, Goto K, Sasaki T. Intraarterial injection of colforsin daropate hydrochloride for the treatment of vasospasm after aneurysmal subarachnoid hemorrhage: preliminary report of two cases. Neuroradiology 2005; 48:50-3. [PMID: 16261335 DOI: 10.1007/s00234-005-0014-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Accepted: 05/24/2005] [Indexed: 10/25/2022]
Abstract
We describe two patients with symptomatic vasospasms after aneurysmal subarachnoid hemorrhage who were successfully treated with intraarterial injection of colforsin daropate hydrochloride (HCl). Colforsin daropate HCl is capable of directly stimulating adenylate cyclase, which in turn causes vasorelaxation via elevated intracellular concentrations of cyclic adenosine monophosphate. We suggest that colforsin daropate HCl might be a useful therapeutic tool in treating cerebral vasospasm.
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Affiliation(s)
- S Suzuki
- Department of Neurological Surgery, Shin-Koga Hospital, Kurume, 830-8577, Japan.
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Abstract
Treatment of acute aneurysmal subarachnoid hemorrhages consists of occluding the aneurysm to prevent rebleed, attempting to prevent vasospasm, and maintaining blood flow to the brain through vessels in vasospasm. Endovascular treatment has been shown to be as safe as, or safer, than surgical clipping for patients with SAH. Engineering solutions to our clinical problems continue to improve endovascular outcomes. This article reviews the current state of endovascular therapy.
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Affiliation(s)
- Stephen Chang
- Department of Radiology and Neurosurgery, Johns Hopkins Medical Institution, Baltimore, MD 21287, USA
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Liu JK, Tenner MS, Gottfried ON, Stevens EA, Rosenow JM, Madan N, MacDonald JD, Kestle JRW, Couldwell WT. Efficacy of multiple intraarterial papaverine infusions for improvement in cerebral circulation time in patients with recurrent cerebral vasospasm. J Neurosurg 2004; 100:414-21. [PMID: 15035276 DOI: 10.3171/jns.2004.100.3.0414] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral vasospasm that is caused by aneurysmal subarachnoid hemorrhage and that is refractory to maximal medical management can be treated with selective intraarterial papaverine infusions. The effects of single papaverine treatments on cerebral circulation time are well known. The purpose of this study was to assess the efficacy of multiple, repeated papaverine infusions on the cerebral circulation time in patients with recurrent vasospasm. METHODS A retrospective study was conducted in 17 patients who received multiple intraarterial papaverine infusions in 91 carotid artery (CA) territories for the treatment of cerebral vasospasm. Cerebral circulation times were measured from the first angiographic image, in which peak contrast was seen above the supraclinoid internal CA, to the peak filling of cortical veins. Glasgow Outcome Scale (GOS) scores assessed 12 months after discharge were reviewed. Cerebral circulation times in 16 CA territories were measured in a control group of 11 patients. Seventeen patients received a total of 91 papaverine treatments. Prolonged cerebral circulation times improved after 90 (99%) of 91 papaverine treatments. The prepapaverine mean cerebral circulation time was 6.54 seconds (range 3.35-27 seconds) and the immediate postpapaverine mean cerebral circulation time was 4.19 seconds (range 2.1-12.6 seconds), an overall mean decrease of 2.35 seconds (36%, p < 0.001). Recurrent vasospasm reflected by prolonged cerebral circulation times continued to improve with subsequent papaverine infusions. Repeated infusions were just as successful quantitatively as the primary treatment (mean change 2.06 seconds). The mean cerebral circulation time in the control group was 5.21 seconds (range 4-6.8 seconds). In five patients a dramatic reversal of low-attenuation changes was detected on computerized tomography scans. The mean GOS score at 12 months after discharge was 3.4. CONCLUSIONS The preliminary results indicate that multiple intraarterial papaverine treatments consistently improve cerebral circulation times, even with repeated infusions in cases of recurrent vasospasm.
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Affiliation(s)
- James K Liu
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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Lang EW, Neugebauer M, Ng K, Fung V, Clouston P, Dorsch NWC. Facial nerve palsy after intracisternal papaverine application during aneurysm surgery--case report. Neurol Med Chir (Tokyo) 2002; 42:565-7. [PMID: 12513030 DOI: 10.2176/nmc.42.565] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 61-year-old woman suffered transient mydriasis and prolonged facial nerve palsy after intracisternal papaverine application subsequent to elective clipping of an unruptured middle cerebral artery aneurysm. The mydriasis resolved within 90 minutes, but the facial nerve dysfunction persisted for 2 months before complete recovery. Prolonged irrigation of the cisterns may have washed the papaverine into contact with the facial nerve. This case supports previously reported evidence of a possible effect of topical intracisternal papaverine hydrochloride application on the facial nerve.
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Affiliation(s)
- Erhard W Lang
- Department of Neurosurgery, Westmead Hospital, University of Sydney, Westmead, New South Wales, Australia.
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Carhuapoma JR, Qureshi AI, Tamargo RJ, Mathis JM, Hanley DF. Intra-arterial papaverine-induced seizures: case report and review of the literature. SURGICAL NEUROLOGY 2001; 56:159-63. [PMID: 11597640 DOI: 10.1016/s0090-3019(01)00450-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Microcatheter-guided intra-arterial (IA) papaverine infusion in conjunction with balloon angioplasty is an available therapy for patients with symptomatic vasospasm after subarachnoid hemorrhage (SAH) that is refractory to hypertensive, hypervolemic therapy. However, side effects and complications have been reported in association with its use. CASE DESCRIPTION We report on a patient who developed symptomatic vasospasm after subarachnoid hemorrhage due to rupture of a left terminal internal carotid artery (ICA) saccular aneurysm. Seven days after the hemorrhage and 4 days after surgical clipping, the patient developed aphasia and right hemiparesis due to vasospasm, which was refractory to maximal medical treatment with volume and blood pressure elevation. Cerebral angiography identified severe narrowing of distal ICA and proximal middle cerebral artery segments bilaterally. These findings partially resolved after balloon angioplasty. However, after 300 mg of IA papaverine, the patient developed generalized convulsions. This occurred despite therapeutic serum levels of phenytoin. Twenty-four hours later, after brief neurologic improvement, recurrent neurologic deficits prompted repeat papaverine administration. Seizures again occurred after the administration of 240 mg of IA papaverine and prevented administration of the full dose. The patient did not develop further seizures and her neurologic deficits continue to resolve. CONCLUSIONS IA papaverine-induced seizures are infrequently reported. This potential complication should be considered when papaverine administration is entertained in the treatment of anterior circulation refractory symptomatic vasospasm after SAH.
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Affiliation(s)
- J R Carhuapoma
- Division of Neurosciences Critical Care, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Nakajima M, Date I, Takahashi K, Ninomiya Y, Asari S, Ohmoto T. Effects of aging on cerebral vasospasm after subarachnoid hemorrhage in rabbits. Stroke 2001; 32:620-8. [PMID: 11239177 DOI: 10.1161/01.str.32.3.620] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The effects of aging on cerebral vasospasm after subarachnoid hemorrhage (SAH) remain to be elucidated. The aim of this study was to clarify age-related differences of vasospasm and of papaverine reactivity in the responses of basilar arteries after SAH in rabbits. METHODS Rabbits receiving a single injection of arterial blood into the cisterna magna were divided into 3 groups: young (2 to 3 months old), adult (6 to 9 months old), and old (20 to 40 months old). Vertebrobasilar angiograms were obtained before SAH and 1, 2, 4, and 7 days after SAH. Papaverine was administrated selectively via the vertebral artery on day 2, and serial angiography was performed for up to 2 hours. Vessel structures were assessed with light microscopy on days 1, 2, 4, and 7 after SAH and at 10, 30, and 60 minutes after papaverine infusion. RESULTS Mortality from SAH in old rabbits was 40%, whereas that of young and adult rabbits was 0%. Angiograms revealed that SAH induced maximal constriction of the basilar arteries on day 2 in all age groups, and the constrictions were significantly increased with age at all time points investigated. The degree of dilatation of spastic basilar arteries after intra-arterial papaverine administration significantly decreased with age. Duration of the efficacy of papaverine became significantly shorter with age. Vessel diameter returned to the preinfusion value approximately 120, 60, and 30 minutes after infusion in young, adult, and old rabbits, respectively. Light microscopy in old rabbits showed luminal narrowing and corrugation of the internal elastic lamina not only in the basilar arteries but also in small arteries and intraparenchymal arterioles. CONCLUSIONS This study suggests that aging increases the degree of vasospasm in rabbits. The impaired reactivity to papaverine with aging might imply the early transition of the aged vessel to the papaverine-resistant chronic stage.
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Affiliation(s)
- M Nakajima
- Department of Neurological Surgery, Okayama University Medical School, Okayama, Japan
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Affiliation(s)
- T P Smith
- Department of Radiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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20
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Papaverine and Vasospasm. J Neurosurg 2000. [DOI: 10.3171/jns.2000.92.3.0509a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Tsurushima H, Kamezaki T, Nagatomo Y, Hyodo A, Nose T. Complications associated with intraarterial administration of papaverine for vasospasm following subarachnoid hemorrhage--two case reports. Neurol Med Chir (Tokyo) 2000; 40:112-5. [PMID: 10786100 DOI: 10.2176/nmc.40.112] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Complications associated with intraarterial papaverine infusion occurred in two patients treated for vasospasm due to subarachnoid hemorrhage (SAH). A 42-year-old male with an anterior communicating artery aneurysm underwent craniotomy and aneurysm clipping. Five days after the SAH occurred, angiography demonstrated moderate vasospasm in spite of hypervolemic-hypertensive therapy. During papaverine infusion into the carotid artery, he suffered loss of consciousness due to a seizure for a few minutes. A 61-year-old female with a right internal carotid-posterior communicating artery aneurysm underwent clipping. Six days after the SAH occurred, angiography demonstrated severe vasospasm in spite of hypervolemic-hypertensive therapy. Angiography performed immediately after papaverine infusion into the carotid artery revealed exacerbation of the vasospasm. Finally she suffered cerebral infarction and died. Complications of intraarterial papaverine infusion are potentially dangerous. We recommend trial administration of papaverine with angiography and neurological examination before full dose infusion to avoid complications.
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Affiliation(s)
- H Tsurushima
- Department of Neurosurgery, Ibaraki Seinam Medical Center Hospital, Japan
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22
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Stordeur JM, Bruder N, Cantais E, Pellissier D, Levrier O, Gouin F. [Monitoring jugular venous oxygen saturation in severe cerebral vasospasm after subarachnoid hemorrhage]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:111-4. [PMID: 10730174 DOI: 10.1016/s0750-7658(00)00111-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Cerebral arterial vasospasm is a major complication of aneurysmal subarachnoid haemorrhage. The conventional treatment of this complication includes haemodilution, hypervolaemia, arterial hypertension and nimodipine. Some patients do not respond to this therapy and require an intraarterial infusion of papaverine and/or a cerebral angioplasty. Transcranial Doppler detects cerebral vasospasm. However it does not provide an accurate metabolic information on the ischaemic status of the cerebral tissue. This article describes the monitoring of jugular venous bulb oxygen saturation to obtain a real time information on the metabolic effect of cerebral vasospasm and its variations after intra-arterial infusion of papaverine.
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Affiliation(s)
- J M Stordeur
- Département d'anesthésie réanimation, CHU Timone, Marseille, France
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Firlik KS, Kaufmann AM, Firlik AD, Jungreis CA, Yonas H. Intra-arterial papaverine for the treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. SURGICAL NEUROLOGY 1999; 51:66-74. [PMID: 9952126 DOI: 10.1016/s0090-3019(97)00370-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intra-arterial papaverine (IAP) has been described as a treatment for cerebral vasospasm refractory to standard therapy. METHODS We report a series of 15 consecutive patients with aneurysmal subarachnoid hemorrhage in which IAP was employed for the treatment of symptomatic vasospasm. All patients exhibited delayed ischemic neurologic deficits, focal cerebral hypoperfusion on stable xenon-enhanced computerized tomography cerebral blood flow studies, and angiographically defined arterial narrowing. Papaverine was infused into 32 arteries on 23 occasions. Six patients required multiple treatments between 1 and 8 days apart. In five instances, IAP was combined with angioplasty. RESULTS Angiographically defined vasospasm was at least partially reversed immediately following treatment on 18 of 23 occasions. The associated clinical improvement was major on 6 occasions, and either minor or none on 17. Post-treatment cerebral blood flow was assessed on 13 occasions and showed improvement in previously ischemic areas on six occasions and no improvement on seven. Complications were encountered on four occasions. Systemic hypotension and transient brain-stem depression were seen with vertebral artery infusions; a generalized seizure and paradoxical aggravation of vasospasm resulting in hemispheric infarction occurred with internal carotid artery infusions. CONCLUSIONS Intra-arterial papaverine resulted in reversal of arterial narrowing in the majority of cases (78%). However, this angiographic improvement was associated with cerebral blood flow augmentation in only 46% of cases analyzed, and major clinical improvement in 26%.
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Affiliation(s)
- K S Firlik
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania, USA
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Wolf EW, Banerjee A, Soble-Smith J, Dohan FC, White RP, Robertson JT. Reversal of cerebral vasospasm using an intrathecally administered nitric oxide donor. J Neurosurg 1998; 89:279-88. [PMID: 9688124 DOI: 10.3171/jns.1998.89.2.0279] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intrathecal bolus administration of (Z)-1-[N-(2-aminoethyl)-N-(2-ammonioethyl)aminio]diazen++ +-1-ium-1,2-diolate (DETA/NO), a long half-life diazeniumdiolate-class nitric oxide (NO) donor, was evaluated for safety and efficacy in the treatment of delayed cerebral vasospasm in a canine model of subarachnoid hemorrhage (SAH). METHODS The baseline basilar artery (BA) diameter of 25 dogs was measured with the aid of angiography on Day 0. Vasospasm was then induced by intracisternal injection of autologous arterial blood on Days 0 and 2. Repeated arteriography on Day 7 revealed an average BA diameter of 58% of baseline. Each dog was then randomized to one of four groups: a pathology control group (SAH only, four animals); a treatment control group (SAH plus 2 micromol of the inactive drug carrier DETA, eight animals); a low-dose treatment group (SAH plus 0.2 micromol DETA/NO, six animals); or a high-dose treatment group (SAH plus 2 micromol DETA/NO, six animals). The drugs were administered in a 2-ml intrathecal bolus via the cisterna magna. Arterial caliber was monitored by angiography over the subsequent 4 hours. A 2-micromol dose of the drug was then given and serial arteriography continued for an additional hour to screen for tachyphylaxis. Intracranial pressure and respiratory and hemodynamic parameters were continuously monitored. Histopathological analyses of the animals' brains were performed after the dogs were killed on Day 8. The drug DETA/NO produced reversal of vasospasm in a dose-dependent fashion that roughly followed a double exponential time course. Doses of 2 micromol DETA/NO resulted in restoration of the angiographically monitored BA diameter to the prevasospasm size at 1.5 hours posttreatment, and this was sustained at 88% of baseline at 4 hours (p < 0.01, independent samples t-test). By contrast, the treatment control group remained on average at 54% of baseline diameter. The low-dose treatment group achieved only partial and more transitory relaxation. Histopathological analyses showed findings consistent with chronic SAH but did not demonstrate any toxicity associated with the NO donor. No adverse physiological changes were seen. CONCLUSIONS This study indicates that long-acting NO donors are potentially useful as agents to restore circulation in patients suffering from cerebral vasospasm.
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Affiliation(s)
- E W Wolf
- Department of Neurosurgery, University of Tennessee Center for the Health Sciences, Memphis 38163, USA.
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25
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Bejjani GK, Bank WO, Olan WJ, Sekhar LN. The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 1998; 42:979-86; discussion 986-7. [PMID: 9588541 DOI: 10.1097/00006123-199805000-00013] [Citation(s) in RCA: 148] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Cerebral angioplasty is being increasingly used for symptomatic vasospasm secondary to subarachnoid hemorrhage. We attempted to determine the safety and efficacy of angioplasty for refractory vasospasm. We also looked at the influence of timing of angioplasty on outcome. METHODS We retrospectively studied patients with subarachnoid hemorrhage who underwent angioplasty in our institution to determine the safety and the success rate achieved with this procedure. The study period extended from August 1993 until February 1997. Clinical and radiological data were collected, with emphasis on clinical improvement after angioplasty and its relationship with timing of intervention. Thirty-one patients with 43 aneurysms and one case of arteriovenous malformations were included. Their ages varied between 28 and 68 years, with an average age of 44 years. Five patients were assigned Hunt and Hess Grade IV, 15 were assigned Grade III, 7 were assigned Grade II, and 4 were assigned Grade I. All patients except two underwent angioplasty after aneurysm clipping or coiling. RESULTS Angioplasty was performed an average of 6.9 days after the occurrence of subarachnoid hemorrhage, with a range from 1 to 14 days. It was performed early (within 24 h) after refractory clinical deterioration in 21 patients. A total of 81 vessels were dilated. Three angioplasty-related complications occurred: two femoral hematomas and one retroperitoneal hematoma. Clinical improvement was dramatic after 12 procedures, moderate after 11 procedures, and minimal or nonexistent after 9 procedures. There was a clear tendency toward more significant improvement in patients with earlier angioplasty (<24 h from onset of neurological deficit) (P=0.0038). At discharge, 8 patients had achieved good recoveries (Glasgow Outcome Scale score of 1), 11 had moderate disabilities (Glasgow Outcome Scale score of 2), and 10 had severe disabilities (Glasgow Outcome Scale score of 3). Two deaths were encountered, and they were unrelated to angioplasty. Follow-up was obtained for 27 patients: 25 had good outcomes, 1 was moderately disabled, and 1 died. There was no significant correlation between interval and outcome. CONCLUSION Our results indicate that angioplasty is a safe and effective treatment for symptomatic vasospasm that is refractory to hyperdynamic hypervolemic therapy. When used early (<24 h), it leads to significant clinical improvement. However, the long-term outcome is good, even in cases of delayed angioplasty. The prevention of worsening of the cerebral ischemia and its extension to other territories may be the reason.
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Affiliation(s)
- G K Bejjani
- Department of Neurological Surgery, George Washington University, Washington, District of Columbia 20037, USA
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26
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Sawada M, Hashimoto N, Tsukahara T, Nishi S, Kaku Y, Yoshimura S. Effectiveness of intra-arterially infused papaverine solutions of various concentrations for the treatment of cerebral vasospasm. Acta Neurochir (Wien) 1997; 139:706-11. [PMID: 9309284 DOI: 10.1007/bf01420042] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We evaluated the effect of intra-arterially infused papaverine solutions of various concentrations on cerebral vasospasm following subarachnoid haemorrhage. A total of 90 vascular territories in 46 patients with symptomatic cerebral vasospasm after subarachnoid haemorrhage were treated with intra-arterial infusions of papaverine. In all patients, papaverine was infused at the top of the internal carotid artery (ICA). Of the 90 vascular territories, 30 vascular territories in 14 patients were treated with an infusion of 0.1-0.2% (weight/volume) papaverine (Group 1), 30 vascular territories in 16 patients were treated with a 0.4% (w/v) papaverine infusion (Group 2), and 30 vascular territories in 16 patients were treated with an infusion of 0.8-2.0% (w/v) papaverine (Group 3). Among the three groups, we compared the vasodilatory effects of papaverine by assessing the angiographical and clinical improvements following the treatment. When 0.4% (w/v) papaverine was infused, 24 vascular territories (80%) were successfully dilated and 7 patients (44%) showed a marked reversal of neurological deficits due to vasospasm. Therefore, 80 mg/20 ml (0.4% (w/v)) papaverine infused over a 10-minute period proved to be a beneficial concentration. Transient focal neurological deficits due to the infusion of papaverine occurred in 1 Group 1 patient (7%), 1 Group 2 patient (6%), and 7 Group 3 patients (44%). Highly concentrated papaverine had a higher risk of temporary deterioration. In conclusion, the papaverine concentration of 0.4% (w/v) infused at the top of the ICA was a safe and adequate concentration for treating cerebral vasospasm.
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Affiliation(s)
- M Sawada
- Department of Neurosurgery, National Cardiovascular Centre, Osaka, Japan
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27
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Fogarty-Mack P, Pile-Spellman J, Hacein-Bey L, Ostapkovich N, Joshi S, Vulliemoz Y, Young WL. Superselective intraarterial papaverine administration: effect on regional cerebral blood flow in patients with arteriovenous malformations. J Neurosurg 1996; 85:395-402. [PMID: 8751623 DOI: 10.3171/jns.1996.85.3.0395] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this study the authors determined the effect of papaverine on regional cerebral blood flow (rCBF) in the angiographically normal arteriolar beds of patients with arteriovenous malformations (AVMs) who underwent transfemoral superselective angiography. Middle cerebral artery (MCA) branch vessels were catheterized during 10 procedures performed in nine patients. The mean (+/- standard deviation) largest AVM diameter was 4.4 +/- 1 cm. Regional CBF was measured by recording the washout of a bolus of xenon-133 injected through the microcatheter. In a dose-ranging study. rCBF and MCA pressure in two patients were repeatedly measured after 3-minute infusions of papaverine at 0.07, 0.7, and 7 mg/minute. In a single-dose study, an additional eight patients received only the highest dose of papaverine administered over a 3-minute period. In the dose-ranging study, CBF increased from baseline in a dose-dependent fashion. In the single-dose study, papaverine increased in rCBF 103%, from 48 +/- 11 to 95 +/- 23 ml/100 g/minute at an MCA pressure of 55 +/- 23 mm Hg. Increase in rCBF was linearly related (y = 2.2x - 17, r2 = 0.84; p = 0.001) to baseline MCA pressure (range 22-84 mm Hg). Papaverine increases rCBF in a direct proportion to baseline MCA pressure, even at low baseline pressures. Selective infusion of vasodilators should be investigated in acute cerebral hypotension to facilitate either primary or collateral recruitment of CBF by aiding spontaneous autoregulatory vasodilation. In addition, rCBF monitoring may be useful in determining the most effective intraarterial dose of papaverine while minimizing complications due to hyperemia.
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Affiliation(s)
- P Fogarty-Mack
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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28
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Clyde BL, Firlik AD, Kaufmann AM, Spearman MP, Yonas H. Paradoxical aggravation of vasospasm with papaverine infusion following aneurysmal subarachnoid hemorrhage. Case report. J Neurosurg 1996; 84:690-5. [PMID: 8613866 DOI: 10.3171/jns.1996.84.4.0690] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Reports of intraarterial papaverine infusion as treatment for cerebral vasospasm are few and documented complications are uncommon. The authors report the case of a patient with paradoxical aggravation of cerebral arterial narrowing during selective intraarterial papaverine infusion intended to treat vasospasm following aneurysmal subarachnoid hemorrhage (SAH). A 48-year-old man presented to the authors' service with symptomatic vasospasm 10 days after experiencing an SAH. The ruptured anterior communicating artery aneurysm was surgically obliterated the following day, and thereafter maximum hypervolemic and hypertensive therapies were used. However, the patient remained lethargic, and a stable xenon-computerized tomography (CT) cerebral blood flow (CBF) study revealed CBF to be 15 cc/100 g/minute in the left anterior cerebral artery (ACA) and 25 cc/100 g/minute in the right ACA territories. Cerebral arteriography demonstrated diffuse severe left ACA and mild left middle cerebral artery (MCA) vasospasm. In response intraarterial papaverine was infused into the internal carotid artery just proximal to the ophthalmic artery. During the infusion the patient became aphasic and exhibited right hemiplegia. Arteriography performed immediately after the intraarterial papaverine infusion revealed diffuse exacerbation of vasospasm in the distal ACA and MCA territories. A repeat xenon-CT CBF study showed that CBF in the left ACA and the MCA had drastically decreased (2 cc/100 g/minute and 10 cc/100 g/minute, respectively). Despite aggressive management, infarction ultimately developed. This is the first clinical case to illustrate a paradoxical effect of intraarterial papaverine treatment for vasospasm following aneurysmal SAH. The possible mechanisms of this paradoxical response and potential therapeutic reactions are reviewed.
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Affiliation(s)
- B L Clyde
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania 15213, USA
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