Intra-arterial Papaverine Research Articles

Intraarterial papaverine for relief of catheter-induced peripheral arterial vasospasm during pediatric cardiac surgery: A randomized double-blind controlled trial.

Maintaining the patency of peripheral arterial lines in pediatric patients during surgery can be challenging due to multiple factors, and catheter-related arterial vasospasm is a potentially modifiable cause. Papaverine, a potent vasodilator, improves arterial line patency when used as a continuous infusion in the pediatric intensive care setting, but this method is not convenient during surgery. Extrapolating from the benefit seen in the intensive care unit, the authors hypothesize that a small-volume intraarterial bolus of papaverine immediately after arterial line placement will reduce vasospasm-related arterial line malfunction. This was a prospective, randomized, double-blind study. Patients less than 17years of age undergoing cardiac surgery were enrolled. Patients were randomized into the heparin or papaverine groups. Immediately after arterial line insertion, an intraarterial bolus of heparin (2units/ml, 1ml) or papaverine (0.12mg/ml, 1ml) was administered (T1, Figure 1). An optimal waveform was defined as the ease of aspirating a standardized blood sample within 30s, absence of cavitation when sampling, absence of color change at the catheter site during injection, and presence of a dicrotic notch. The primary outcome evaluated was the presence of an optimal arterial waveform at 5min after the first randomized dose (T1+5min). The secondary outcomes were the presence of optimal arterial waveform an hour after the first dose and the ability of papaverine to rescue suboptimal waveforms. A total of 100 patients were enrolled in the study. Twelve patients were excluded from the analysis. Complete datasets after randomization were available in 88 patients (heparin group, n=46; papaverine group, n=42). At baseline, groups were similar for age, weight, arterial vessel size, and arterial line patency. At T1+5min, an improvement in the waveform characteristics was observed in the papaverine group (heparin,39% [8/46] vs. papaverine, 64% [27/42]; p=.02; odds ratio, 2.8; 95% CI, 1.2 to 6.6, Figure 3, Table 2). At the end of 1h, both groups showed continued improvement in arterial line patency. After the second dose, a higher number of patients in the heparin group had suboptimal waveforms and were treated with papaverine (heparin,37% [17/46] vs. papaverine,17% [7/42], p=.05). Patients in the heparin group treated with papaverine showed significant improvement in patency (13/17 vs. 3/7, p=.01). No serious adverse events were reported. In pediatric patients, papaverine injection immediately after peripheral arterial catheter placement was associated with relief of vasospasm and improved initial arterial line patency. Further, papaverine can be used as a rescue to improve and maintain arterial line patency.

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.

Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage.

Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic “triple‐H” therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.

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.

Vascular flow reserve immediately after infrapopliteal intervention as a predictor of wound healing in patients with foot tissue loss.

The purpose of this study was to verify whether the concept of coronary blood flow reserve can be applied to patients with critical limb ischemia who are undergoing endovascular treatment (EVT) for isolated infrapopliteal lesions. Forty patients diagnosed with critical limb ischemia (Rutherford category 5) who were undergoing EVT for isolated infrapopliteal lesions were prospectively enrolled. All lesions were treated with conventional balloon angioplasty without stent placement. After successful EVT, a pressure/temperature sensor-tipped guidewire was positioned in the proximal popliteal artery. Using the thermodilution technique, the mean transit time (Tmn) was determined after bolus injections of 3-mL saline at baseline and at the onset of intra-arterial papaverine induced maximum hyperemia. Vascular flow reserve (VFR) was calculated as resting Tmn divided by hyperemic Tmn. Complete epithelialization of the reference wound (wound healing) was completely closed by either surgical or secondary intervention within 3 months after EVT. Wound healing was achieved in 22 patients after EVT (healing group) but was not achieved in 18 patients (nonhealing group). Postprocedural VFR was significantly lower in the nonhealing group than in the healing group (2.40; interquartile range, 2.00-3.08 versus 4.05; interquartile range, 3.60-4.60; P<0.0001). Receiver operating characteristic analysis revealed postprocedural VFR >3.6 as the best threshold value for complete wound healing after EVT. Univariate analysis revealed that postprocedural VFR >3.6 was a predictor of wound healing (P=0.0002). Advanced lower limb clinical setting may be caused by a poor capability of microvasculature. VFR, which is easily assessable, is useful in clinical risk stratification for patients with critical limb ischemia after EVT in the catheterization laboratory. URL: http://www.umin.ac.jp/ctr. Unique identifier: UMIN000009313.

Assessment of lower limb flow and adequate intra-arterial papaverine doses to achieve maximal hyperemia in elder subjects.

Previous studies reported that invasive physiological assessment for significance of the lesions in the patients with claudication under the condition of pharmacological hyperemia was important to identify the patients who will benefit from revascularization. However, the maximal hyperemic response in lower limb and the method to induce maximum dilatation of vascular bed in lower limb were not well established. The aim of this study was to investigate the range of maximal hyperemic response in lower limb of the normal subjects and to identify the ideal lower limb vasodilatory stimulation. Twelve limbs without stenotic lesions from 12 subjects (average age: 72±6years) were analyzed. Thermodilution-derived mean transit time (Tmn) was obtained at baseline and during pharmacological hyperemia with incremental dose of intra-arterial papaverine (10, 20, 30, and 40mg) using a 0.014-inch pressure/temperature sensor-tipped wire in the superficial femoral artery (SFA). Percent increase in blood flow (%IBF) of lower limb was defined as the ratio between baseline Tmn and hyperemic Tmn. Mean ankle brachial index score of the subjects was 1.14±0.09. The %IBF values were enhanced by papaverine in a dose-dependent manner. A dose of 30mg of intra-arterial papaverine was sufficient to achieve maximum hyperemia (%IBF: range 219-769%). In conclusion, the increase in blood flow of lower limb during maximal hyperemia varied between individuals and maximal hyperemia can be achieved with 30mg of papaverine for the SFA lesion.

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.

Predictors of Severity of Cerebral Vasospasm caused by Aneurysmal Subarachnoid Hemorrhage

Cerebral vasospasm is one of the leading causes of poor outcome after aneurysmal subarachnoid hemorrhage. The risk factors for the development of vasospasm have been evaluated in many clinical studies. However, it remains unclear if vasospasm severity can be predicted. The purpose of this study was to determine if different demographic and clinical factors that appear to be predictors of vasospasm can also prognosticate the severity of cerebral vasospasm. We retrospectively analyzed consecutive patients with subarachnoid hemorrhage who underwent endovascular vasospasm treatment in a single center. In order to define predictors of vasospasm severity, we studied the demographic and clinical characteristics of these patients. Vasospasm severity was defined by cerebral angiography, transcranial Doppler ultrasound, and therapeutic response on endovascular treatment. Statistical analyses were performed to determine significant predictors. A total of 70 patients with vasospasm were included. Early onset of mean flow velocities>160 cm/second on transcranial Doppler ultrasound correlated with severity of angiographic vasospasm (P=.0469) and resistance against intra-arterial papaverine (P=.0277). Younger age (<51 years of age) was significantly associated with severity of vasospasm regarding extension on angiography (P=.0422), the need for repetitive endovascular treatment (P=.0084), persistence of transcranial Doppler ultrasound vasospasm after endovascular treatment (P=.0004), and resistance against intra-arterial papaverine (P=.0341). Younger age and early onset of vasospasm on transcranial Doppler ultrasound are important predictors for vasospasm severity. We recommend early and aggressive therapy in this subgroup.

Effect of intraarterial papaverine or nimodipine on vessel diameter in patients with cerebral vasospasm after subarachnoid hemorrhage

Introduction. Papaverine (P) and nimodipine (N) are the most widely used vasodilators when angiographic and symptomatic vasospasm is present after subarachnoid aneurysmatic hemorrhage (SAH). Their effect is only short-lived and no direct comparisons have been undertaken to evaluate the action of both substances directly. We retrospectively assessed the effect of either P or N on angiographic diameter reduction and capillary blood flow. Methods. Fifteen SAH patients with secured aneurysms and cerebral vasospasm received intraarterial P, fifteen similar patients received N. As the primary endpoint, pre- and post-infusion arterial diameters and capillary blood flow were rated retrospectively on angiographies and compared by RM-ANOVA. Secondary endpoints were the difference in the modified Rankin Scale between the two groups on admission and at discharge, the occurrence of delayed cerebral ischemia, the separate effects on angiographic diameter and capillary blood flow and the overall response rate to the vasodilator infusion. Results. Angiographic resolution of diameter reduction and angiographically assessed capillary blood flow together differed not significantly between both groups. P infusion dilated all angiographic demonstrable vessels while N infusion was ineffective in 16% of the patients. Capillary flow on pre- and post-infusion angiographies was not different between the two groups. Conclusion. P and N seem to differ in the effect on cerebral diameter reduction in patients with vasospasm after SAH. The clinical implications remain to be established. A multimodal approach, perhaps combining different agents for intraarterial infusion in such patients, needs to be evaluated.

Retention and fracture of a hydrophilic radial artery sheath due to severe spasm

Worldwide, there is increasing interest in transradial intervention, as it appears safer, more cost-effective and is the preferred access route for patients over transfemoral intervention. The favorable neuroanatomical relationships of the radial artery mean that access-site complications are extremely rare. However, radial access-site complications do occur and we report a case of radial artery spasm preventing radial sheath removal, refractory to repeated administration of radial artery vasodilators, intra-arterial papaverine and conscious sedation. Sheath removal was ultimately only possible using an open surgical approach. Radial operators need to be aware of the management of this rare but significant clinical complication.

Critical Care Guidelines on the Endovascular Management of Cerebral Vasospasm

Cerebral vasospasm and delayed cerebral ischemia account for significant morbidity and mortality after aneurysmal subarachnoid hemorrhage. While most patients are managed with triple-H therapy, endovascular treatments have been used when triple-H treatment cannot be used or is ineffective. An electronic literature search was conducted to identify English language articles published through October 2010 that addressed endovascular management of vasospasm. A total of 49 articles were identified, addressing endovascular treatment timing, intra-arterial treatments, and balloon angioplasty. Most of the available studies investigated intra-arterial papaverine or balloon angioplasty. Both have generally been shown to successfully treat vasospasm and improve neurological condition, with no clear benefit from one treatment compared with another. There are reports of complications with both therapies including vessel rupture during angioplasty, intracranial hypertension, and possible neurotoxicity associated with papaverine. Limited data are available evaluating nicardipine or verapamil, with positive benefits reported with nicardipine and inconsistent benefits with verapamil.

Cerebral vasospasm after subarachnoid hemorrhage from severe arteriovenous malformation

Dear Editor,We read with great interest the article entitled“Outcomeof severe arteriovenous malformation-related intracranialhemorrhage: the importance of cisternal subarachnoidhemorrhage and early seizures.” by Rahme et al. [4]Theauthors reviewed the records of 16 consecutive patientswho presented with severe arteriovenous malformation(AVM)-related intracranial hemorrhage. They reportedthat three patients, who had subarachnoid hemorrhage(SAH), died from extensive bihemispheric infarction andrefractory intracranial pressure. Statistical analysisrevealed that SAH and early seizures were significantlyassociated with death. We completely agree with theauthors’ findings and wish to provide further comment.Cerebral vasospasm after SAH from AVM has beenreported to occur in 8-31% of patients [1, 3]. We believethat cerebral vasospasms might be one of the attributablefactors for cerebral infarctions in the three patients whodied in the authors’ series. We consider that physiciansneed to be particularly aware of cerebral vasospasm inpatients with massive SAH from AVM, and that thethreshold of digital subtraction angiography, computedtomography angiography, or magnetic resonance angiographyshouldbeloweredforearlydetectionofcerebralvasospasminpatients with SAH from AVM. Additionally, nimodipine,nicardipine, intra-arterial papaverine, or angioplasty may beefficient for preventing or treating cerebral vasospasm afterSAH from AVM [2, 3, 5]. However, treatment of cerebralvasospasm may augment blood flow to an untreated AVMand promote early rebleeding, especially in cases withuntreated intranidal aneurysms [2, 3, 5]. Early AVM resectioncan prevent rebleeding and also enable treatment of cerebralvasospasm. We consider that early AVM resection andawareness of cerebral vasospasm are required in patientswith massive SAH from AVM.

Effects of intra-arterial papaverine on the chronic period of cerebral arterial vasospasm in rats.

The effect of intra-arterial papaverine (IAP) on the basilar artery (BA) and cerebral perfusion pressure (CPP) during the chronic period of the cerebral arterial vasospasm in rats was investigated. The study was carried out on male, Swiss-Albino rats, the weight of each varied between 200-340 g. A large volume (0.3 cc) of nonheparinized, autolog blood was utilized in order to cause a subarachnoid haemorrhage. For the measurement of the changes in BA diameter, the angiograms were made prior to the subarachnoid haemorrhage, 48 h after the subarachnoid haemorrhage, and in 1, 15, 30, and 60 min after papaverine infusion into the vertebral artery. The BA vascular index was found separately for each angiogram. At each stage of the procedure mean arterial blood pressure (MAP) and intracranial pressure (ICP) were monitored. BA diameter measurements were found to be 226+/-32 microm in pre-haemorrhage angiograms and 145+/-44 microm in angiograms 48 h after the subarachnoid haemorrhage. In the angiograms immediately after IAP, it was found that the BA diameter reached about 92% (206+/-41 microm) of control values. But, in the angiograms 15 min after IAP, it was observed that BA underwent a spasm again. The dilatator effect of IAP on BA was temporary. Additionally, in the chronic vasospasm period when cerebral autoregulation mechanisms are impaired and CPP decreased significantly, IAP has adversely affected CPP decreasing MAP.

Symptomatic Cerebral Vasospasm after Surgical Ligation of Unruptured Aneurysms

Background Cerebral artery vasospasm accounts for the majority of delayed neurological deficits in ruptured aneurysm patients. We report two cases and review the literature" of patients who developed symptomatic vasospasm after treatment for unruptured cerebral artery aneurysms with clip ligation. Pre- and post-operative imaging and studies revealed absence of subarachnoid or focal hemorrhage. Case Description In a series of 104 consecutive cerebral artery aneurysm patients that underwent uncomplicated ligation without intra-operative rupture, two patients developed delayed neurologic deficits due to severe cerebral vasospasm. Both patients had no stigmata of rupture and were treated electively. Post-operative transcranial dopplers and angiography facilitated the early recognition of vasospasm. Permanent neurologic injury was prevented with the use of hypertensive, hemodilution and hyperdynamic (HHH) therapy along with endovascular treatment, intra-arterial papaverine and angioplasty. Conclusion After uncomplicated treatment of unruptured intracranial aneurysms, the cerebral vasculature may proceed to severe vasospasm by an unrecognized mechanism. This can be reversed with institution of HHH and endovascular therapy.

Ventral Intramedullary Cervical Spinal Cord AVM

Background Cerebral artery vasospasm accounts for the majority of delayed neurological deficits in ruptured aneurysm patients. We report two cases and review the literature" of patients who developed symptomatic vasospasm after treatment for unruptured cerebral artery aneurysms with clip ligation. Pre- and post-operative imaging and studies revealed absence of subarachnoid or focal hemorrhage. Case Description In a series of 104 consecutive cerebral artery aneurysm patients that underwent uncomplicated ligation without intra-operative rupture, two patients developed delayed neurologic deficits due to severe cerebral vasospasm. Both patients had no stigmata of rupture and were treated electively. Post-operative transcranial dopplers and angiography facilitated the early recognition of vasospasm. Permanent neurologic injury was prevented with the use of hypertensive, hemodilution and hyperdynamic (HHH) therapy along with endovascular treatment, intra-arterial papaverine and angioplasty. Conclusion After uncomplicated treatment of unruptured intracranial aneurysms, the cerebral vasculature may proceed to severe vasospasm by an unrecognized mechanism. This can be reversed with institution of HHH and endovascular therapy.

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.

The effect of intra-arterial papaverine on ECoG activity in the ketamine anesthetized rat

The opium alkaloid papaverine (PPV) causes vasodilatation of the cerebral arteries through direct action on smooth muscle that reduces the constriction of smooth muscle. Intra-arterial papaverine (IAP) has been used widely to increase the regional cerebral blood flow in order to reverse the cerebral vasospasm that occurs during endovascular procedures. IAP-induced seizures have been reported, although PPV has anticonvulsive effects. This study determined the effects of IAP on electrocorticography (ECoG) in the ketamine anesthetized rats. We used 24 Sprague–Dawley male rats weighing 200–250 g. The animals were divided randomly into four groups: three treatment groups (groups 1–3) and a control (group 4). Groups 1, 2, and 3 were given 1, 7, and 14 mg/kg IAP, respectively. The ECoG was compared across groups. Our results indicated that IAP did not cause seizures and that it decreased the frequency of ketamine-induced epileptiform activity in the 14 mg/kg group.

Perfusion CT to Evaluate the Effect of Transluminal Angioplasty on Cerebral Perfusion in the Treatment of Vasospasm After Subarachnoid Hemorrhage

IntroductionDelayed ischemic neurologic deficits secondary to vasospasm are a major cause of morbility and mortality after subarachnoid hemorrhage (SAH). Treatment of vasospasm after SAH is associated with complications, and reliable techniques for evaluating effects of treatment of vasospasm in such patients are warranted. We present the use of perfusion computed tomography (PTC) to evaluate the effect of transluminal percutaneous angioplasty in a with SAH and vasospasm-induced ischemiia.MethodsDynamic PCT with deconvolution produced maps of time-to-peak, mean transit time, regional cerebral blood flow, and regional cerebral blood volume, with a computerized automated map of the infarct and penumbra. CT scanners with quadruple detector array were used before and after angioplasty.ResultsBefore angioplasty and intraarterial papaverine, PCT showed normal to decreased cerebral blood flow and increased cerebral blood volume and mean transit time in the middle cerebral artery territory of the left hemisphere. After angioplasty and intraarterial papaverine, PCT showed normalization of perfusion parameters.ConclusionPCT can be a useful technique in monitoring angioplasty treatment effects in patients with vasospasm after SAH.

Haemodynamic changes after intracisternal papaverine instillation during intracranial aneurysmal surgery

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.