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Intraarterial Papaverine Infusion for Cerebral Vasospasm after Subarachnoid Hemorrhage

Intraarterial Papaverine Infusion for Cerebral Vasospasm after Subarachnoid Hemorrhage,John E. Clouston,Gregg H. Zoarski,E. Francois Aldrich,J. Marc S

Intraarterial Papaverine Infusion for Cerebral Vasospasm after Subarachnoid Hemorrhage   (Citations: 35)
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PURPOSE: To evaluate the techniques and efficacy of intracranial intraarterial papaverine infusion for symptomatic vasospasm after subarachnoid hemorrhage caused by aneurysm rupture. METHODS: Papaverine was infused on 19 occasions in 14 patients, 6 hours to 2 days after spasm became apparent clinically. Sixty vascular territories were treated. Infusion was made into the supraclinoid internal carotid artery 20 times, cavernous internal carotid artery once, selective A1 anterior cerebral artery 8 times, M1 middle cerebral artery 7 times, and basilar artery 3 times. Papaverine doses ranged from 150 to 600 mg and exceeded 400 mg on 8 occasions. RESULTS: Angiographic improvement occurred in 18 (95%) of the 19 treatment sessions: results were excellent in 3 sessions, moderate in 8, and mild in 7. The best angiographic results often were obtained with superselective infusion, although angiographic results did not always correlate with clinical response. Seven (50%) of the 14 treated patients showed dramatic acute clinical improve- ment within 24 hours of papaverine therapy, and there was no clinical evidence of recurrent vasospasm in these patients. Recurrence of angiographic vasoconstriction was demonstrated in three patients; one showed marked clinical improvement after a second treatment. There were no episodes of systemic hypotension in any of the cases. Monocular blindness developed in one patient because of papaverine infusion near the ophthalmic artery. CONCLUSIONS: Papaverine was effective in dilating narrowed arteries in most patients with symptomatic vasospasm caused by subarachnoid hemorrhage. This series showed encouraging clinical results with no recurrence of neurologic deterioration in those patients who responded well to papaverine. Superselective infu- sion appears to be indicated in some cases for adequate papaverine delivery.
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    • ...Alternatively, superselective infusions into either ACA or MCA distributions can be performed by directing the microcatheter more distally into the desired vascular territory (10,28)...
    • ...Papaverine improves CBF by effectively increasing the angiographical vessel diameter (Fig. 1) in the proximal, intermediate, and distal cerebral arteries (16,19,28,31)...
    • ...One of the major disadvantages of intra-arterial papaverine treatment is its transient nature, which may result in recurrent and/or persistent angiographical and clinical vasospasm that may require multiple infusions (14,16,21,28)...
    • ...Most reports lack a statistically significant correlation between the clinical outcomes and the angiographical response to intra-arteria l papaverine (19,28,46)...
    • ...Reported complications include rapid increases in ICP (30), transient neurological deficits (including mydriasis [47] and brainstem depression [48,49]), monocular blindness (28), seizures (14,28,43,50), thrombocytopenia (51), precipitation of crystal emboli during infusion (27), and paradoxical exacerbation of vasospasm leading to cerebral infarction (52)...
    • ...Reported complications include rapid increases in ICP (30), transient neurological deficits (including mydriasis [47] and brainstem depression [48,49]), monocular blindness (28), seizures (14,28,43,50), thrombocytopenia (51), precipitation of crystal emboli during infusion (27), and paradoxical exacerbation of vasospasm leading to cerebral infarction (52)...

    James K. Liuet al. Intra-arterial papaverine infusions for the treatment of cerebral vaso...

    • ...In previously reported series, the proportion of intracranial vessels responding to endovascular treatment was 57 % [23] after nonsuperselective papaverine treatment, 92 % after papaverine infusion and PTA [24] and 95 % [36] and 97 % [39] following superselective papaverine...
    • ...These results compare favourably with other series which describe sustained clinical improvement in 25 % [23], 50 % [36], 67 % [39] and 69 % [19] of patients following intravascular papaverine...

    B. Schuknechtet al. Endovascular treatment of cerebral vasospasm: assessment of treatment ...

    • ...It has been used as the sole treatment for vasospasm following aneurysmal subarachnoid haemorrhage [13, 15, 18], or in combination with angioplasty [7, 10, 11, 14], with promising results...
    • ...As the use of papaverine treatment has increased, investigators have reported frequent recurrence of vasospasm after successful initial angiographic vasodilatation [11, 13, 18]...
    • ...Some of our earlier results have been described previously [18]...
    • ...There seems to be general agreement that intra-arterial papaverine frequently reverses vasospasm but the angiographic results do not always correlate with the clinical outcome [11, 13, 18]...
    • ...Papaverine has been administered by continuous pump infusion during 30‐60 min [13, 15] or manually during 10‐20 min [18]...
    • ...However, our previous experience [18] and the current study revealed no early or late clinical deterioration in any patient who showed acute significant neurologic improvement after single or multiple papaverine treatments...
    • ...Despite the results of these animal studies, we found no apparent correlation between clinical outcome after papaverine infusion and the time since the subarachnoid haemorrhage or severity of vasospasm in either our previous report [18] or the current study...

    Y. Numaguchiet al. Repeat intra-arterial papaverine for recurrent cerebral vasospasm afte...

    • ...Some previous studies of this treatment reported a relatively small number of patients with variable success rates [8, 9, 18, 19] and other reports have described complications associated with papaverine infusion [1-3, 6, 10, 13-15]...
    • ...Complications in the central nervous system during the intra-arterial infusion of papaverine for vasospasm have previously been reported [1-3, 6, 9, 10, 13-15]...
    • ...Kassell et aI. [9] reported that 60% of their patients treated with papaverine who had angiographic improvement in vasospasm had no clinical benefit, and Clouston et al. [2] stated that 50% of their patients had no clinical benefit despite angiographic improvement...

    M. Sawadaet al. Effectiveness of intra-arterially infused papaverine solutions of vari...

    • ...Clouston et al (26) treated 14 patients on 19 occasions, using a PPV dose ranging from 150 to 600 mg (exceeding 400 mg on eight occasions)...

    Naomi Fujiwaraet al. Intraarterial Infusion of Papaverine in Experimental Cerebral Vasospas...

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