Intra-arterial Administration Of Verapamil Research Articles

Quantifying Intra-Arterial Verapamil Response as a Diagnostic Tool for Reversible Cerebral Vasoconstriction Syndrome.

There is mounting evidence supporting the benefit of intra-arterial administration of vasodilators in diagnosing reversible cerebral vasoconstriction syndrome. We prospectively quantified the degree of luminal diameter dilation after intra-arterial administration of verapamil and its accuracy in diagnosing reversible cerebral vasoconstriction syndrome. Patients suspected of having intracranial arteriopathy on noninvasive imaging and referred for digital subtraction angiography were enrolled in a prospective registry. Intra-arterial verapamil was administered in vascular territories with segmental irregularities. The caliber difference (Caliberpost - Caliberpre) and the proportion of caliber change ([(Caliberpost - Caliberpre)/Caliberpre] × 100%) were used to determine the response to verapamil. The diagnosis of reversible cerebral vasoconstriction syndrome was made on the basis of clinical and imaging features at a follow-up appointment, independent of the reversibility of verapamil. Receiver operating characteristic curve analysis was performed to determine the best threshold. Twenty-six patients were included, and 9 (34.6%) were diagnosed with reversible cerebral vasoconstriction syndrome. A total of 213 vascular segments were assessed on diagnostic angiography. Every patient with a final diagnosis of reversible cerebral vasoconstriction syndrome responded to intra-arterial verapamil. The maximal proportion of change (P < .001), mean proportion of change (P = .002), maximal caliber difference (P = .004), and mean caliber difference (P = .001) were statistically different between patients with reversible cerebral vasoconstriction syndrome and other vasculopathies. A maximal proportion of change ≥32% showed a sensitivity of 100% and a specificity of 88.2% to detect reversible cerebral vasoconstriction syndrome (area under the curve = 0.951). The Reversible Cerebral Vasoconstriction Syndrome-2 score of ≥5 points achieved a lower area under the curve (0.908), with a sensitivity of 77.8% and a specificity of 94.1%. Objective measurement of the change in the arterial calibers after intra-arterial verapamil is accurate in distinguishing reversible cerebral vasoconstriction syndrome from other vasculopathies. A proportion of change ≥32% has the best diagnostic performance.

First case series of the transradial approach for neurointerventional procedures in pediatric patients.

The transradial approach (TRA) has been widely adopted by interventional cardiologists but is only now being accepted by neurointerventionalists. The benefits of the TRA over the traditional transfemoral approach (TFA) include reduced risk of adverse clinical events and faster recovery. The authors assessed the safety and feasibility of the TRA for neurointerventional cases in the pediatric population. Pediatric patients undergoing cerebrovascular interventions since implementation of the TRA at the authors' institution were retrospectively reviewed. Pertinent patient information, procedure indications, vessels catheterized, fluoroscopy time, and complications were reviewed. There were 4 patients in this case series, and their ages ranged from 13 to 15 years. Each patient tolerated the procedure performed using the TRA without any postprocedural issues, and only 1 patient experienced radial artery spasm, which resolved with the administration of intraarterial verapamil. None of the patients required conversion to the TFA. The TRA can be considered a safe alternative to the TFA for neurointerventional procedures in the pediatric population and provides potential advantages. However, as pediatric patients require special consideration due to their smaller-caliber arteries, routine use of ultrasound guidance is advised when attempting the TRA.

Intra-arterial administration of verapamil for prevention and treatment of cerebral angiospasm after SAH due to cerebral aneurysm rupture

The study purpose was to analyze the efficacy of intra-arterial administration of verapamil (IAV) in the treatment of angiospasm in SAH patients and to determine optimal parameters of the procedure. A number of studies demonstrated the efficacy of intra-arterial administration of vasodilators, in particular verapamil, in the treatment of angiospasm after aneurysmal SAH, which served the basis for inclusion of this method in the recommended protocol for treatment of SAH patients [1-7]. We analyzed the efficacy of IAV in 35 patients in the acute period of SAH, with 77.2% of the patients having a Hunt-Hess score of III-V. The inclusion criteria were as follows: IAV within two weeks after SAH; excluded aneurysm; verapamil dose per administration of at least 15 mg; follow-up for at least three months. Efficacy endpoints were as follows: changes in spasm according to angiography and transcranial dopplerography (TCDG); development of ischemic lesions; clinical outcome according to the modified Rankin scale. A total of 76 IAV procedures were performed. The verapamil dose per procedure was 36.7±9.7 mg, on average; the number of procedures varied from 1 to 5. One arterial territory was treated in 12 cases, two arterial territories were treated in 48 cases, and three arterial territories were treated in 15 cases. Typical adverse reactions included decreased blood pressure, a reduced heart rate, and elevated ICP. In all cases, TCDG revealed signs of reduced angiospasm - a 20-40% decrease in the LBFV in the M1 MCA. Four (11.4%) patients died; of these, only one died due to angiospasm progression. On examination at 3 months or more after discharge, favorable outcomes were observed in 74.3% of cases. IAV is associated with a low risk of significant complications. IAV should be performed under control of systemic hemodynamics and ICP. The indications for IAV include signs of moderate worsening or severe angiospasm according to TCDG and/or angiography. The IAV procedure may be performed every day. Further clarification of the IAV procedure and evaluation of clinical outcomes under prospective study conditions are required.

Case-Control Study of Intra-arterial Verapamil for Intraprostatic Anastomoses to Extraprostatic Arteries in Prostatic Artery Embolization for Benign Prostatic Hypertrophy

PurposeIt is hypothesized that intra-arterial administration of verapamil is a safe and effective way to reverse the flow in intraprostatic anastomoses to extraprostatic arteries without compromising treatment outcomes in prostatic artery embolization (PAE) for benign prostatic hypertrophy (BPH). Materials and MethodsA prospective study of 62 prostate sides in 31 consecutive patients (median age, 66 y; range, 60–71 y) with symptomatic BPH was undertaken. Median prostate volume was 72.4 mL (range, 48.8–85.8 mL), median International Prostate Symptom Score was 21 (range, 15-23), and median urine peak flow rate was 4 mL/s (range, 2–6 mL/s). The arterial anastomoses were classified as types I–III according to vascular morphology. Treatment safety was assessed in terms of adverse events and complications, and treatment effectiveness was assessed in terms of success rate of angiographic flow reversal. ResultsThe PAE procedure was successfully completed in all 31 patients (100%). Adverse events in both groups were transient and mild and did not necessitate prolonged hospitalization. There was no clinical evidence of any significant nontarget ischemic complication in either group. Intraprostatic anastomosis was diagnosed in 19 of 31 patients (61.3%) and 22 of 62 prostate sides (35.5%). Success rates of verapamil treatment were 88.9% overall (20 of 22) and 100% (19 of 19) in type II and III anastomoses. There was no difference between the treatment group and the control group in clinical, urologic, and imaging outcomes of PAE. ConclusionsIntra-arterial verapamil treatment was probably safe and effective in causing flow reversal in type II and III intraprostatic anastomoses and in preventing ischemic complications in PAE for BPH without compromising PAE outcomes.

Stroke neuroprotection revisited: Intra-arterial verapamil is profoundly neuroprotective in experimental acute ischemic stroke

While clinical trials have now solidified the role of thrombectomy in emergent large vessel occlusive stroke, additional therapies are needed to optimize patient outcome. Using our previously described experimental ischemic stroke model for evaluating adjunctive intra-arterial drug therapy after vessel recanalization, we studied the potential neuroprotective effects of verapamil. A calcium channel blocker, verapamil is often infused intra-arterially by neurointerventionalists to treat cerebral vasospasm. Such a direct route of administration allows for both focused targeting of stroke-impacted brain tissue and minimizes potential systemic side effects. Intra-arterial administration of verapamil at a flow rate of 2.5 µl/min and injection volume of 10 µl immediately after middle cerebral artery recanalization in C57/Bl6 mice was shown to be profoundly neuroprotective as compared to intra-arterial vehicle-treated stroke controls. Specifically, we noted a significant (P ≤ 0.05) decrease in infarct volume, astrogliosis, and cellular apoptosis as well as a significant increase in neuronal survival and functional outcome over seven days. Furthermore, intra-arterial administration of verapamil was well tolerated with no hemorrhage, systemic side effects, or increased mortality. Thus, verapamil administered intra-arterially immediately following recanalization in experimental ischemic stroke is both safe and neuroprotective and merits further study as a potential therapeutic adjunct to thrombectomy.

Abstract W P259: Selective Intra-arterial Administration of Verapamil is Neuroprotective in Acute Ischemic Stroke

Despite the urgent need for better stroke therapies, experimental stroke treatments have largely failed to translate to stroke patients. In an effort to bridge this translational gap, we have concentrated our efforts on drugs that are already FDA approved and associated with treating stroke-associated pathophysiology, such as cerebral artery vasospasm, with the goal of repurposing them to protect brain tissue from ischemic injury. Verapamil, a calcium channel blocker, is one such drug that is often infused intra-arterially by neurosurgeons treating vasospasm that results in ischemia. In demonstrating a reliable and reproducible stroke mouse model ( transient middle cerebral artery occlusion, MCAo) with the addition of a retro-engineered IA drug delivery model mimicking the human condition, we were able to optimize the injection volume and flow rate for pharmacotherapy administration of verapamil. Through this direct route of administration we have shown a significant decrease (P&lt;0.001) in infarct volume and trending towards significance an increase in behavioral outcome when comparing treated animals versus control. Perfusion studies did not show significant differences in perfusion to account for vasomotor changes as the likely mechanism for ischemia reduction. To further explore this, after 1 hour MCAo in three month old C57/Bl6 mice, we examined the potential neuroprotective effects of verapamil on post stroke day 3. Whole brains were harvested and flash frozen for cryostat sectioning and cellular staining to compare apoptosis, appearance of mature neurons, astrocyte activation and synaptic stability. Results suggest that IA administration of verapamil, more specifically than reducing infarct volume, is directly neuroprotective on brain parenchymal tissue at risk.

E-009 Reversible cerebral vasoconstriction syndrome following carotid artery stenting

IntroductionReversible cerebral vasoconstriction syndromes (RCVS) compromise a group of disorders characterized by prolonged but reversible vasoconstriction of the cerebral arteries. RCVS has been reported to occur in various clinical settings...

Repetitive use of intra-arterial verapamil in the treatment of reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) typically presents with recurrent thunderclap headaches and neurological deficits that are usually self-limiting. The intra-arterial (IA) use of vasodilators for RCVS has been reported for severe cases. Patients with RCVS have the potential for serious and permanent neurological deficits. It is a rare disorder, with a recent surge in the number of reports, and probably continues to be under-diagnosed. We report two patients with RCVS with severe neurological sequelae, treated in a large tertiary hospital. Both patients received high-dose cortico steroids due to the possibility of angiitis of the central nervous system, but they deteriorated neurologically, which suggests that steroids may have a deleterious effect in RCVS. Treatment with IA verapamil resulted in reversal of vasoconstriction, but multiple treatments were necessary. Therefore, IA administration of verapamil is a possible treatment for severe RCVS, but there is only limited sustained improvement in vasodilation that may require repetitive treatments with a currently undetermined optimal treatment interval.