Ultrahigh-dose intraarterial infusion of verapamil through an indwelling microcatheter for medically refractory severe vasospasm: initial experience

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  • 1 Georgia Neurosurgical Institute, Mercer University School of Medicine, Macon, Georgia;
  • 2 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
  • 3 Department of Neurosurgery, Louisiana State University, New Orleans, Louisiana
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Object

Vasospasm is one of the leading causes of morbidity and death following aneurysmal subarachnoid hemorrhage (SAH). Many patients suffer devastating strokes despite the best medical therapy. Endovascular treatment is the last line of defense for cases of medically refractory vasospasm. The authors present a series of patients who were treated with a prolonged intraarterial infusion of verapamil through an in-dwelling microcatheter.

Methods

Over a 1-year period 12 patients with medically refractory vasospasm due to aneurysmal SAH were identified. Data were retrospectively collected, including age, sex, Hunt and Hess grade, Fisher grade, aneurysm location, aneurysm treatment, day of the onset of vasospasm, intracranial pressure, mean arterial pressures, intraarterial treatment of vasospasm, dosages and times of verapamil infusion, presence of a new ischemic area on CT scan, modified Rankin scale score at discharge and at the last clinical follow-up, and discharge status.

Results

Twenty-seven treatments were administered. Between 25 and 360 mg of verapamil was infused per vessel (average dose per vessel 164.6 mg, range of total dose per treatment 70–720 mg). Infusion times ranged from 1 to 20.5 hours (average 7.8 hours). The number of treated vessels ranged from 1 to 7 per patient. The number of treatments per patients ranged from 1 to 4. There was no treatment-related morbidity or death. Blood pressure and intracranial pressure changes were transient and rapidly reversible. Among the 36 treated vessels, prolonged verapamil infusion was completely effective in 32 cases and partially effective in 4. Only 4 vessels required angioplasty for refractory vasospasm after prolonged verapamil infusion. There was no CT scanning evidence of new ischemic events in 9 of the 12 patients treated. At last clinical follow-up 6–12 months after discharge, 8 of 11 patients had a modified Rankin Scale score ≤2.

Conclusions

Prolonged intraarterial infusion of verapamil is a safe and effective treatment for medically refractory severe vasospasm and reduces the need for angioplasty in such cases.

Abbreviations used in this paper: ACA = anterior cerebral artery; ACoA = anterior communicating artery; HHH = hypertension-hypervolemia-hemodilution; ICA = internal carotid artery; ICP = intracranial pressure; MAP = mean arterial pressure; MCA = middle cerebral artery; mRS = modified Rankin Scale; PCA = posterior cerebral artery; SAH = subarachnoid hemorrhage; SCA = superior cerebellar artery; TCD = transcranial Doppler; VA = vertebral artery.

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Contributor Notes

Address correspondence to: Erminia Albanese, M.D., Georgia Neurosurgical Institute, Mercer University School of Medicine, 840 Pine Street, Suite 880, Macon, Georgia 31201. email: erminiaalb@yahoo.it.

Please include this information when citing this paper: published online October 30, 2009; DOI: 10.3171/2009.9.JNS0997.

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