Intra-arterial Infusion Of Papaverine Research Articles

Local Intra-arterial Vasodilator Infusion in Non-Occlusive Mesenteric Ischemia Significantly Increases Survival Rate

PurposeTo investigate the outcome of local intra-arterial papaverine infusion therapy in patients with non-occlusive mesenteric ischemia (NOMI), and factors influencing survival, in comparison with a conservative approach.MethodsFrom 2013 to 2019, patients with NOMI confirmed by imaging were included in a retrospective two-center study. According to different in-house standard procedures, patients were treated in each center either conservatively or interventionally by a standardized local infusion of intra-arterial papaverine into the splanchnic arteries. Thirty-day mortality and factors influencing the outcome, such as different demographics and laboratories, were compared between groups using Kaplan–Meier survival analysis and Cox regression, respectively.ResultsA total of 66 patients with NOMI were included, with n = 35 treated interventionally (21 males, mean age 67.7 ± 12.3 years) and n = 31 treated conservatively (18 females, mean age 71.6 ± 9.6 years). There was a significant difference in 30-day mortality between the interventional (65.7%; 12/35 survived) and the conservative group (96.8%; 1/31 survived) (hazard ratio 2.44; P = 0.005). Thresholds associated with a worse outcome of interventional therapy are > 7.68 mmol/l for lactate, < 7.31 for pH and < − 4.55 for base excess.ConclusionLocal intra-arterial papaverine infusion therapy in patients with NOMI significantly increases survival rate in comparison with conservative treatment. High lactate levels, low pH and high base excess, and high demand for catecholamines are associated with a poor outcome.Level of EvidenceLevel III.

Below-the-Ankle Arrival Time as a Novel Limb Tissue Perfusion Index: Two-dimensional Perfusion Angiography Evaluation

Purpose: To identify lower limb 2-dimensional (2D) perfusion angiographic parameters that are related to skin perfusion pressure (SPP), a predictor of wound healing in patients with chronic limb-threatening ischemia (CLTI) undergoing below-the-knee (BTK) endovascular treatment (EVT). Materials and Methods: Thirty-three consecutive patients (mean age 74.5 years; 18 men) with 47 isolated BTK lesions in 33 limbs (Rutherford category 3–5) underwent EVT. Dorsal and plantar SPPs were measured before EVT and the day after. The indexed blood flow below the ankle was measured using 2D perfusion angiography before and after EVT to determine changes in perfusion parameters [arrival time (AT), time to peak, wash-in rate, mean transit time, and width and area under the time-density curve] at rest vs during hyperemia induced with a 20-mg intra-arterial papaverine infusion. Correlations between the 2D perfusion parameters and SPPs were assessed using the Pearson coefficient. The cutoff points to predict mean SPPs >40 mm Hg were analyzed using a receiver operating characteristic curve; outcomes are reported as the area under the curve (AUC) with 95% confidence interval (CI). Results: After EVT at rest and during hyperemia, only AT was significantly changed, although hyperemia produced significant changes in all the pre-/post-EVT 2D perfusion parameters except the wash-in rate. Dorsal and plantar SPPs after EVT were significantly increased and correlated with hyperemic AT and the AT ratio (hyperemia/at rest values) below the ankle. Hyperemic ATs <6.3 seconds and AT ratios <0.78 were predictive factors for a mean SPP >40 mm Hg, with AUCs of 0.83 (95% CI 0.67 to 0.99) and 0.78 (95% CI 0.61 to 0.95), respectively. Conclusion: Hyperemic ATs <6.3 seconds or AT ratios <0.78 below the ankle may be essential to obtain sufficient SPPs for limb salvage in BTK lesions. Thus, the use of 2D perfusion angiography enabled the monitoring of lower limb tissue perfusion throughout EVT and may thereby optimize treatment of CLTI.

P3395Arrival time at hyperemia of below the ankle as a determinant factor for limb salvage: evaluation by 2 dimension perfusion angiography

Abstract Background In patients with critical limb ischemia, it is desirable to obtain enough skin perfusion pressure (SPP) levels through revascularization. 2D-perfusion angiography is an emerging technology for the quantification of tissue perfusion consisted of 6 parameters calculated by time-density curve of digital subtraction angiography (DSA). Purpose We evaluated the feasibility of 2D-perfusion angiography for below the knee (BTK) endovascular therapy (EVT). We aimed to clarify which angiographical parameters of lower limb are related to SPP after EVT. Methods Consecutive 33 limbs (mean age 74.5 years, men 55%), which successfully underwent EVT for isolated BTK lesions, were enrolled in this study. We excluded Rutherford 6 limbs with severe gangrene or tissue loss, consequently 26 limbs were Rutherford 4 or 5 critical limb ischemia. We treated total 47 lesions, including 26 chronic total occlusive lesions. 5Fr guiding sheath was advanced to popliteal artery. DSA images were obtained by mechanical contrast infusion. We quantified indexed blood flow on below the ankle area by using 2D-perfusion angiography, and examined 6 parameters [arrival time (AT), time to peak (TTP), wash-in rate, width, area under the curve and mean transit time (MTT)] from acquired DSA. Hyperemia was induced by 20mg papaverine intra-arterial infusion through the guiding sheath. Results The parameters except wash-in rate were significantly shortened after hyperemia induced by intra-arterial papaverine infusion below the ankle region. Dorsal and plantar SPP were significantly correlated with hyperemic AT, hyperemic wash-in rate and AT ratio (hyperemic/rest) of lower ankle regions after EVT. However, only AT ratio was independently associated with dorsal SPP in multivariate analysis (P=0.032). A receiver operating characteristic curve showed hyperemic AT &lt;4.5 seconds and AT ratio &lt;0.49 predicted to obtain SPP levels &gt;50 mmHg after EVT with the area under the curve of 0.71 (95% confidence interval, 0.52–0.90) and 0.73 (95% confidence interval, 0.55–0.90), respectively. Representative Case of 2D-perfusion Conclusion Hyperemic AT &lt;4.5 seconds and AT ratio &lt;0.49 of lower ankle regions may be essential to obtain the sufficient levels of SPP for limb salvage after BTK intervention. 2D perfusion angiography technique at hyperemic condition is feasible and has the potential to monitor lower limb tissue perfusion through EVT and to optimize the interventional treatment.

Non-occlusive mesenteric ischemia associated with enteral feeding after esophagectomy for esophageal cancer: report of two cases and review of the literature

BackgroundNon-occlusive mesenteric ischemia (NOMI) is a rare but life-threatening complication of early postoperative enteral feeding. We herein report two patients who developed NOMI during enteral feeding after esophagectomy.Case presentationIn case 1, a 75-year-old man with no medical history was diagnosed with multiple primary cancers of the esophagus, stomach, and kidney. He underwent percutaneous endoscopic gastrostomy tube placement followed by thoracoscopic esophagectomy and cervical esophagostomy placement as the first-stage operation. Gastrostomy feeding was started on postoperative day (POD) 3 with a polymeric formula (ENSURE H®). On POD 7, he developed acute abdominal pain and distension with bloody drainage through the gastrostomy tube. Dynamic computed tomography showed massive hepatic portal venous gas and pneumatosis intestinalis. Angiography showed diffuse spasms in the branches of the superior mesenteric artery. Under a diagnosis of NOMI, we started intra-arterial infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 48.In case 2, a 68-year-old man with diabetes and atrial fibrillation was diagnosed with esophageal cancer. His medical history was significant for pylorus-preserving gastrectomy for gastric cancer and small bowel resection for trauma. He underwent thoracoscopic esophagectomy, open total gastrectomy, colonic reconstruction, and jejunostomy tube placement. Adhesiolysis for abdominal severe adhesions caused by previous operations was difficult. Jejunostomy feeding was started on POD 3 with a polymeric formula (Racol®). On POD 7, he developed persistent diarrhea and cervical anastomotic leakage. On POD 9, he developed acute abdominal pain and distension with bloody drainage through the jejunostomy tube. Dynamic computed tomography showed the same findings as in case 1. Under a diagnosis of NOMI, we started intravenous infusion of papaverine and prostaglandin E1. His symptoms improved, and he was discharged on POD 28.ConclusionsThe causes of feeding-related NOMI may include the use of a high-osmolarity formula, preoperative malnutrition, abdominal adhesiolysis, systemic inflammation after anastomotic leakage, and a medical history of diabetes and atrial fibrillation. NOMI should be considered as a differential diagnosis in patients with these risk factors and clinical features such as acute abdominal pain and distension during enteral feeding.

Intra-arterial Administration of Papaverine during Mechanical Thrombectomy for Acute Ischemic Stroke

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. 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. 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. 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.

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.

Response to Letter by Menon and Norris

HomeStrokeVol. 38, No. 5Response to Letter by Menon and Norris Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Letter by Menon and Norris Wibke G. Janzarik Peter A. Ringleb Matthias Reinhard and Sebastian Rauer Wibke G. JanzarikWibke G. Janzarik Department of Neurology, University of Freiburg, Freiburg, Germany Search for more papers by this author Peter A. RinglebPeter A. Ringleb Department of Neurology, Ruprecht-Karls University of Heidelberg, Heidelberg, Germany Search for more papers by this author Matthias ReinhardMatthias Reinhard Department of Neurology, University of Freiburg, Freiburg, Germany Search for more papers by this author and Sebastian RauerSebastian Rauer Department of Neurology, University of Freiburg, Freiburg, Germany Search for more papers by this author Originally published15 Mar 2007https://doi.org/10.1161/STROKEAHA.106.480202Stroke. 2007;38:e17Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: March 15, 2007: Previous Version 1 Response:Norris and Menon suspect that both patients whom we reported to have recurrent vasospasms of the internal carotid artery1 were likely to have carotid artery dissection (CAD). In fact, CAD had been the initial diagnosis in both patients. There were, however, several findings which could not be explained in the context of CAD and led us to the assumption of internal carotid artery vasospasm.We agree that MRI with MR angiography is sensitive in the diagnosis of CAD. Ultrasound detects dissection mainly by its hemodynamic sequelae than by depiction of the vessel wall hematoma itself, particularly in submandibular dissection. It may thus not consistently differentiate between vasospasm and dissection in case of poor insonation conditions. In both of our patients, T1-fat–suppressed MRI (several times in patient 1, once during the course of repeated high-grade stenoses in patient 2) had been performed. However, no wall hematoma was detected in MRI2 or in repeated sonographic examinations with insonation conditions allowing clear depiction of the vessel wall. The possibility to perform repeated sonographic examinations as a noninvasive monitoring with detection of recurrent high-grade stenoses gave the ultrasound method a high impact during the clinical course of our patients.In both patients we observed repeated changes in severity and side of stenosis within days. A resolution of CAD within 2 days from high-grade stenosis to no stenosis, which implies the rapid reabsorption of a considerable carotid wall hematoma, is not very plausible. Moreover, recurrence of arterial dissection in the same vessel is rare.3 In addition, we documented a regression of a high-grade internal carotid artery stenosis during intraarterial infusion of papaverine which cannot be explained by CAD.Migraine is a moderate risk factor for CAD.4 On the other hand, migraine is known to go along with vasospasms.5 In 1 of our 2 patients, migrainous headaches had occurred for several years. They were clearly associated with the recurrent vasospasms. We therefore suggest that in this patient recurrent vasospasms had regularly occurred long before the ischemic event. We do not know whether vasospasms occurred during a migraine attack or whether the pulsatile headaches were secondary to vasospasm.In both patients we observed no stabilization of the vascular situation for several weeks, and the patients were repeatedly at high risk for new ischemic events. Both patients received antithrombotic therapy to prevent thromboembolic complications—the same rationale is used to justify antithrombotic treatment in CAD. This modus operandi in CAD has not yet been investigated in a randomized trial.6 Assuming that the observed high-grade stenoses of internal carotid artery were caused by vasospasms, we additionally initiated an antivasospastic treatment as well as, in patient 2, an antiphlogistic treatment.DisclosuresNone.1 Janzarik WG, Ringleb PA, Reinhard M, Rauer S. Recurrent extracranial carotid artery vasospasms: report of 2 cases. Stroke. 2006; 37: 2170–2173.LinkGoogle Scholar2 Ozdoba C, Sturzenegger M, Schroth G. Internal carotid artery dissection: MR imaging features and clinical-radiologic correlation. Radiology. 1996; 199: 191–198.CrossrefMedlineGoogle Scholar3 Pelkonen O, Tikkakoski T, Leinonen S, Pyhtinen J, Lepojarvi M, Sotaniemi, K. Extracranial internal carotid and vertebral artery dissections: angiographic spectrum, course and prognosis. Neuroradiology. 2003; 45: 71–77.CrossrefMedlineGoogle Scholar4 Pezzini A, Granella F, Grassi M, Bertolino C, Del Zotto E, Immovilli P, Bazzoli E, Padovani A, Zanferrari C. History of migraine and the risk of spontaneous cervical artery dissection. Cephalalgia. 2005; 25: 575–580.CrossrefMedlineGoogle Scholar5 Rothrock JF, Walicke P, Swenson MR, Lyden PD, Logan WR. Migrainous stroke. Arch Neurol. 1988; 45: 63–67.CrossrefMedlineGoogle Scholar6 Lyrer P, Engelter S. Antithrombotic drugs for carotid artery dissection. Stroke. 2004; 35: 613–614.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails May 2007Vol 38, Issue 5 Advertisement Article InformationMetrics https://doi.org/10.1161/STROKEAHA.106.480202 Originally publishedMarch 15, 2007 PDF download Advertisement

Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage

Cerebral vasospasm remains a major source of morbidity and death in patients with aneurysmal subarachnoid hemorrhage (SAH). When vasospasm becomes refractory to maximal medical management consisting of induced hypertension and hypervolemia and administration of calcium channel antagonists, endovascular therapies should be considered. The primary goal of endovascular treatment is to increase cerebral blood flow to prevent cerebral infarction. Two of the more frequently studied endovascular treatments are transluminal balloon angioplasty and intraarterial papaverine infusion. These two have been used either alone or in combination for the treatment of vasospasm. Other pharmacological vasodilating agents currently being investigated are intraarterial nimodipine, nicardipine, verapamil, and milrinone. Newer intraarterial agents, such as fasudil and colforsin daropate, have also been investigated. In this article the authors review the current options in terms of endovascular therapies for treatment of cerebral vasospasm. The mechanism of action, technique of administration, clinical effect and outcomes, and complications of each modality are discussed.

Vasopressin as adjunct vasopressor for vasodilatory shock due to non-occlusive mesenteric ischemia

We present the case of an 83-year-old patient who underwent cardiac surgery and developed postoperative non-occlusive mesenteric ischemia (NOMI), which was treated with a local intra-arterial papaverine and prostaglandin E1 infusion. After successful mesenteric reperfusion, a multiple organ dysfunction syndrome with severe cardiovascular failure developed. High norepinephrine dosages (1.09 microg/kg body weight/min) and catecholamine-related complications (tachycardiac atrial fibrillation) required initiation of supplementary argininevasopressin (AVP) infusion (4 U/h). AVP stabilized vasodilatory shock, ensured adequate gut perfusion pressure and had no adverse clinical or angiographic effects on restitution of gut integrity. In conclusion, after reperfusion of NOMI in this patient, adjunct AVP therapy combined with local vasodilator infusion was beneficial as a potentially life-saving vasopressor.

The Role of Transcranial Color Duplex Ultrasound in Endovascular Treatment of Cerebral Vasospasm

Introduction Recent advances in neuroradiology have made it possible to perform superselective catheterization of the intracranial arteries. Intra-arterial papaverine infusion (PI) or percutaneous transluminal balloon angioplasty (PTA) can then be performed to treat vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to determine the correlation between the angiographic result and transcranial color duplex ultrasound (TCDU) and to define a velocity threshold that could be used to predict the success of endovascular treatment for vasospasm. Methods Seven patients with SAH and symptomatic cerebral vasospasm underwent endovascular therapy and daily TCDU. PTA and/or PI was performed on a total of 23 arterial segments. Fifteen arterial segments were treated once, and eight segments required a second or third intervention. Preintervention and postintervention TCDU velocities were compared with angiographic results. Results Good to excellent relief of spasm was reported in 15 segments on the basis of postintervention angiography. The average preintervention TCDU velocity for these 15 responders was 170 cm/sec. Velocities dropped to an average of 96.5 cm/sec immediately after intervention. For the eight nonresponders, the average velocity pretreatment was 128 cm/sec. Angiography demonstrated modest or no relief of spasm after PTA or PI, and the average velocity after treatment was 130 cm/sec. When a change of &gt;25 cm/sec was used, TCDU correctly predicted angiographic responders with a p value of &lt; 0.01. Conclusions Our data demonstrate a strong correlation between the angiographic result and the drop in velocity after endovascular therapy for vasospasm. Postintervention TCDU values can be used as a point of reference from which to monitor further progression or regression of vasospasm. We believe that TCDU has significant value in the management decisions of endovascular interventions for the treatment of cerebral vasospasm.

Intradural Aneurysm Caused by Arterial Injury during Surgery

We described a patient with subarachnoid hemorrhage due to a ruptured intradural aneurysm caused by arterial injury during surgery and severe symptomatic vasospasm. The iatrogenic posttraumatic aneurysm was occluded by using GDC with preservation of parent artery followed by intraarterial infusion of papaverine to treat vasospasm as an one-stage procedure. This resulted in significant angiographic resolution of the vasospasm and the patient's clinical outcome was excellent. Endovascular approach to posttraumatic intracranial aneurysms and endosaccular GDC embolization of aneurysm with concomitant intraarterial papaverine infusion to treat vasospasm are discussed.

Quantitative Analysis of Papaverine-Mediated Blood–Brain Barrier Disruption in Rats

The blood–brain barrier (BBB) is a permeability barrier of interconnected brain capillary endothelial cells. Intraarterial infusion of papaverine relieves cerebral vasospasms by inhibiting smooth muscle contractions and it may simultaneously lead to a disruption of BBB permeability. To date, the mechanism underlying this phenomenon and the quantification of BBB disruption remains elusive. We first examined the changes in cerebrovascular permeability after an intracarotid infusion of papaverine (0.20%) in rats by an in situ brain perfusion technique. We then demonstrated that changes in cerebrovascular permeability depend on the concentration of papaverine. This is the first study in which the degree of BBB disruption was accurately quantified in terms of [14C]sucrose and it was demonstrated that papaverine has a prolonged effect on cerebrovascular permeability. This result suggests the importance of in vivo experiments for a precise evaluation of permeability for many other agents, particularly for the central nervous system.

Intra-arterial papaverine-induced seizures: case report and review of the literature

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.

Milrinone for the treatment of cerebral vasospasm after subarachnoid hemorrhage: report of seven cases.

The intra-arterial infusion of papaverine has been used for dilation of spastic cerebral vessels after aneurysmal subarachnoid hemorrhage, although its efficacy is controversial. Milrinone is an inotropic drug that dilates vessels by phosphodiesterase inhibition in a mechanism similar to that of papaverine. We examined the effects of intra-arterial and subsequent intravenous administration of milrinone on patients with symptomatic cerebral vasospasm. Seven patients with cerebral vasospasm were enrolled in this study. Milrinone was delivered intra-arterially via catheter at a rate of 0.25 mg/min. The total delivered dose was between 2.5 and 15 mg. Radiological measurement of the middle cerebral artery diameter and cerebral blood flow was carried out before and after arterial infusion. Intravenous treatment followed at 0.50 or 0.75 microg/kg/min for up to 2 weeks from the onset of subarachnoid hemorrhage. Dilation of the vasospastic vessels occurred in all patients. The rate of cerebral blood flow was calculated in six patients and was increased in all. Subsequent intravenous infusion was effective in preventing a recurrence of symptomatic vasospasm in four of the seven patients. It is suggested that milrinone was effective and safe for the treatment of cerebral vasospasm after subarachnoid hemorrhage in the patients in this series. Intra-arterial infusion with adjunctive intravenous infusion holds promise as a clinically advantageous treatment regimen.

Antiischemic therapy of severe prolonged vasospasm after aneurysmal SAH: effects on quality of life.

The in-between broad acceptance of early surgery and improved intensive care management have led to a significant reduction of vasospasm associated morbidity and mortality within the last 25 years. However, the large body of publications concerned with the prevention and treatment of vasospasm still denote its role as one of the major complications in the postoperative management after aneurysmal subarachnoid hemorrhage (SAH). Next to purely mechanical measures such as balloon dilatation of vasospastic vessels and intraarterial papaverine infusion, which as of now lack verification by means of larger controlled clinical trials, established medical treatment concepts focus on pharmacological approaches such as the calcium antagonist nimodipine and hypervolemic hemodilution and hypertension (“Triple-H” therapy).KeywordsSAHvasospasmtriple-H therapyquality of life

Angiogenic therapy for the chronically ischemic lower limb in a rabbit model.

The purpose of this study was to evaluate the long-term effectiveness of basic fibroblast growth factor (bFGF) in achieving neovascularization following ischemia from arterial ligation and to determine an optimal dosage level. We used an Ameroid constrictor to produce progressive occlusion of the left femoral artery of rabbits. At 2 weeks, the rabbits were randomized to receive intravenous injection of vehicle (group A, n = 15); 3 microg/kg/day bFGF (group B, n = 12); 10 microg/kg/day bFGF (group C, n = 12); or 16 microg/kg/day bFGF (group D, n = 15) for 3 days. At 1 to 37 days after surgery, we assessed limb neovascularization by transcutaneous oximetry (TCPO(2)), angiography, heart rate, arterial pressure, peripheral vascular resistance (PRU), and muscle blood flow (MBF) during steady-state intra-arterial infusion of saline (basal), acetylcholine, papaverine, or serotonin under anesthesia and capillary density (cap/mm(2)) and capillary per muscle fiber ratio (cap/F). Groups B and C showed significantly greater change in TCPO(2) over time than groups A and D (P < 0.0001). Group D showed the lowest TCPO(2) values from days 14 to 37 and group C the highest. Groups B and C showed a higher number of vessels filled with contrast agent than groups A and D (P < 0.0001). Calf cap/mm(2) and cap/F were significantly higher in groups B and C than groups A and D (P < 0.0001). Calf basal MBF values were higher in groups B and C than in groups A and D, but were not statistically significant. Group D showed the highest level in basal PRU. There were no significant differences in heart rate or blood pressure among the groups. These results show (1) treatment with bFGF has no adverse hemodynamic effects, (2) bFGF enhances angiogenesis and circulation at moderate doses, and these effects persist at least several weeks, and (3) high doses of bFGF may inhibit angiogenesis and collateral circulation.

Angiographic Cerebral Circulation Time Before and After Endovascular Therapy for Symptomatic Vasospasm

AIM: To investigate the correlation between angiographic cerebral circulation time (CCT) and cerebral blood flow (CBF) evaluated by single photon emission computed tomography (SPECT) before and after endovascular treatment for symptomatic vasospasm.MATERIALS AND METHODS: Seven patients with unilateral vasospasm as demonstrated by catheter angiography who underwent pre- and post-treatment SPECT were selected. All patients had angiographic vasospasm of unilateral middle cerebral artery (MCA). Eight vessels in seven patients underwent intra-arterial papaverine infusion and three vessels underwent percutaneous transluminal angioplasty. Angiographic CCT was defined as the interval from the first image in which contrast medium was visible at the origin of MCA to its disappearance from the cortical arteries in the MCA territory. In SPECT studies, the ischaemic degree in MCA territory was analysed by side to side comparison with calculating the asymmetry index (AI).RESULTS: The pre-treatment mean CCT was 4.1±0.8s. The mean CCT immediately after treatment was 2.7±0.5s. In the control subjects (n=15) with unruptured aneurysm, mean CCT was 3.5±0.2s. The pre-treatment mean CCT was significantly prolonged compared with that in the control subjects (P=0.02). The post-treatment mean CCT was significantly shortened compared with that in the control subjects (P=0.001). The pre-treatment mean AI was 71.2±7.4%, and that immediately after treatment was 90.5±3.6%. AI increased in all territories treated with endovascular treatment; the mean change was 19.3%. Angiographic CCT was closely correlated with AI in both pre- (r=−0.95) and post-treatment (r=−0.79).CONCLUSION: Measurement of CCT is useful in evaluating cerebral haemodynamics of endovascular treatments in patients with cerebral vasospasm.Iseda, T., (2000). Clinical Radiology55, 679–683.

Monitorage de la saturation veineuse jugulaire en oxygène au cours d'un vasospasme cérébral sévère après hémorragie sous-arachnoïdienne

Jugular venous oximetry in a patient with severe cerebral vasospasm after subarachnoid haemorrhage. 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 intra-arterial 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.

Complications Associated with Intraarteriul Administration of Papaverine for Vasospusm Following Subarachnoid Hemorrhage. Two Case Reports.

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.

ENDOVASCULAR THERAPY FOR ANEURYSMAL VASOSPASM

Endovascular treatment of cerebral vasospasm induced by subarachnoid hemorrhage has become a useful therapy. The two main treatments that have been used are balloon angioplasty and intra-arterial papaverine infusion. Both treatments have been shown to reverse subarachnoid hemorrhage-induced vascular spasm, increase cerebral blood flow and improve delayed ischemic neurologic deficits induced by vasospasm. Balloon angioplasty is superior to papaverine for treatment of proximal vessel vasospasm by virtue of a more sustained effect on the vessels. Papaverine can be useful as an adjunct to balloon angioplasty and also for the treatment of distal vessels that are not accessible for balloon angioplasty.