Improvement in Angiographic Cerebral Vasospasm after Intra-Arterial Verapamil Administration

J.V. Sehy; W.E. Holloway; S.-P. Lin; D.T. Cross; C.P. Derdeyn; C.J. Moran

doi:10.3174/ajnr.A2215

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Fig 1.
Anteroposterior views of left vertebral angiograms from patient 4 obtained after presentation with SAH (A) and 12 days later before (B) and after (C) treatment with 10-mg intra-arterial verapamil. The arrowhead in A indicates a dissecting aneurysm of the right AICA, which was subsequently coil-embolized. The arrow in B indicates the right P2 PCA segment, which improved from 50% stenosis to 38% stenosis with treatment. The arrowheads in C indicate improvement in angiographic vasospasm in the superior cerebellar arteries and distal left VA, analysis of which was beyond the scope of this study.
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Fig 2.
Scatterplot demonstrating improvement in angiographic cerebral vasospasm after treatment with intra-arterial verapamil. During 16 procedures in 12 patients, 34 arterial distributions were selectively treated. Cerebral angiograms were obtained after patient presentation with SAH and days later before and after intra-arterial verapamil treatment of cerebral vasospasm. Artery diameters were measured in a blinded fashion at multiple predetermined sites (whether or not vasospasm was present) in each arterial distribution from each of the 3 angiograms, and the resulting 275 data points were plotted.
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Fig 3.
Subgroup analysis of all arterial segments with history of angioplasty treatment demonstrating improvement in recurrent angiographic cerebral vasospasm after treatment with intra-arterial verapamil. Data from 4 procedures in 3 patients documenting 11 treatment changes in 9 arterial segments were plotted. Treatment response was not different in arterial segments with a history of recent angioplasty treatment compared with other arterial segments (P > .05).

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Table 1:

Demographics, SAH grade, aneurysm management, and intra-arterial vasospasm treatment in 12 patients who collectively underwent 16 procedures

Pt/Procedure No.	Age (yr)/Sex	HH Grade	Fisher Grade	Aneurysm Location, Treatment	Findings Prompting Treatment	PHD When Treated	Vessel, Verapamil Infused (mg)
1/1	42/M	4	3	L AChoA, clip	Confusion, R drift	6	R ICA, 10
							L ICA, 10
							R VA, 10
1/2					Confusion	10	R ICA, 10
							L ICA, 10
2	42/M	3	3	L MCA, clip	Aphasia	6	L ICA, 10
3	43/F	3	3	R PcomA, clip	Confusion, agitation	15	R ICA, 10
							L ICA, 10
							R VA, 5
4	19/F	2	3	R AICA, coil	L weakness, L drift	12	R ICA, 10
							L ICA, 10
							L VA, 10
5	39/F	4	3	R AChoA, clip; R MCA, clip	L hemiparesis	16	R ICA, 20
6	49/F	4	3	R SHA, none	Bilateral lower extremity paresis	13	R ICA, 10
							L ICA, 10
7/1	34/F	2	4	None	Global aphasia	6	R ICA, 10
							L ICA, 10
							R VA, 10
7/2					Global aphasia	11	R ICA, 10
							L ICA, 10
							R VA, 10
8/1	57/F	2	3	L PcomA, clip	R hemiparesis, expressive aphasia	5	R ICA, 10
							L ICA, 20
8/2					R hemiparesis, expressive aphasia	8	R ICA, 10
							L ICA, 10
8/3					L frontoparietal infarct	11	L ICA, 10
9	59/F	2	3	AcomA, clip	Confusion	1^{^a}	R ICA, 10
10	59/F	2	3	AcomA, coil	Bilateral ACA infarcts	9	R ICA, 10
							L ICA, 10
11	48/F	3	3	AcomA, clip	L neglect, L drift	7	R ICA, 10
							L ICA, 10
12	45/F	4	3	R MCA, clip	L hemiparesis	4	R ICA, 10
							L ICA, 10
							L VA, 10

a Headache, photophobia, nausea, and vomiting began 5 days prior to admission and diagnosis.

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Table 2.

Hemodynamic parameters during 16 procedures involving intra-arterial vasospasm treatment in 12 patients

Pt/Procedure No.	Total Verapamil (mg)	HHH Therapy	HR (bpm)		MAP (mm Hg)			ICP (mm Hg)
Pt/Procedure No.	Total Verapamil (mg)	HHH Therapy	Initial	Nadir	Initial	Nadir	Goal	Initial	Peak
1/1	30	No	102	57	108	86		17	17
1/2	20	No	85	79	104	96		4	4
2	10	Yes^{^a}	68	60	117	97	120–130	7	8
3	25	No	96	96	83	76		10	12
4	30	No	78	75	114	91
5	20	Yes^{^a}	125	100	85	71	120–130
6	20	Yes^{^a}	87	80	136	100	120–130
7/1	30	No^{^a}	95	86	129	112		6	10
7/2	30	Yes^{^a}	94	91	130	130	145–155
8/1	30	No	73	64	77	64
8/2	20	Yes^{^a}	95	84	134	111	125–140
8/3	10	Yes^{^a}	125	94	117	103	135–145
9	10	No	85	68	85	81
10	20	No	131	106	114	112		16	20
11	20	No	65	65	103	98		7	8
12	30	No	90	86	105	95		15	15