Improvement of cerebral oxygenation patterns and metabolic validation of superselective intraarterial infusion of papaverine for the treatment of cerebral vasospasm

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Object. The purpose of the present study was to assess cerebral oxygenation patterns and brain lactate concentration changes before, during, and after intraarterial infusion of papaverine with or without balloon angioplasty in patients with symptomatic vasospasm.

Methods. A total of 23 vascular territories were successfully treated in 10 patients. In three patients balloon angioplasty was performed before the papaverine infusion. Continuous monitoring of jugular bulb vein oxygen saturation with a fiberoptic catheter and blood sampling allowed the assessment of the cerebral arteriovenous oxygen and lactate differences. A significant and rapid improvement in jugular bulb oxygen saturation was observed in all cases, with critical values reflecting an improvement in cerebral oxygenation after endovascular treatment of vasospasm (p = 0.005). Lactate concentration in the jugular bulb normalized within 4 hours in all patients who had evidence of brain lactic acidosis before superselective intraarterial infusion of papaverine. Recurrence of abnormal metabolic and oxygenation patterns were observed in one case in which an optimal hypertension and hypervolemic therapy could not be achieved after the procedure.

Conclusions. Improvement in cerebral oxygenation as well as prevention of cerebral lactic acidosis can be successfully achieved after intraarterial infusion of papaverine. Normalization of the oxygen supply after endovascular treatment has to be supported by optimal and well-monitored hypertension and hypervolemic hemodilution.

Article Information

Address reprint requests to: Javier Fandino, M.D., Department of Neurosurgery, University Hospital of Zürich, Rämistrasse 100, 8091 Zürich, Switzerland.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 4. Upper Left: Right ICA angiogram documenting symptomatic vasospasm of the supraclinoid segment of the right ICA. Upper Right: Angiogram obtained after balloon angioplasty in the proximal segment of the right MCA with intraarterial infusion of papaverine in the A1 and A2 segments of the ACA and the M2 segment of the MCA. Lower Left: Graph showing that the mean velocity of the proximal MCA (MCAre) normalized (80 cm/second) and blood sampling of the ipsilateral jugular bulb showed a decrease in lactate production by the brain. Lower Right: Online monitoring of SvjO2 confirming an improvement in the cerebral oxygenation up to 77%. PPV = papaverine.

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    Case 6. Upper Left: Axial CT scan obtained after rupture of a right posterior communicating artery in a patient with initial Hunt and Hess Grade II. Upper Right: Angiogram obtained on Day 10 post-SAH confirming symptomatic vasospasm of the supraclinoid segment of the right carotid artery, MCA, and ACA. Lower Left: Angiogram obtained after superselective infusion of papaverine demonstrating successful dilation of the vessels. No additional angioplasty was performed. Lower Right: Online monitoring of the ipsilateral jugular bulb oxygen saturation demonstrating a rapid improvement in cerebral oxygenation from 58 to 78% during papaverine (PPV) infusion.

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    Graphs showing SvjO2 (left) and AVDL (right) before and after infusion of papaverine in 10 patients.

References

1.

Barnwell SLHigashida RTHalbach VVet al: Transluminal angioplasty of intracerebral vessels for cerebral arterial spasm: reversal of neurological deficits after delayed treatment. Neurosurgery 25:4244291989Neurosurgery 25:

2.

Cruz JMiner MEAllen SJet al: Continuous monitoring of cerebral oxygenation in acute brain injury: assessment of cerebral hemodynamic reserve. Neurosurgery 29:7437491991Neurosurgery 29:

3.

Eskridge JMNewell DWPendleton GA: Transluminal angioplasty for treatment of vasospasm. Neurosurg Clin North Am 1:3873991990Neurosurg Clin North Am 1:

4.

Firlik ADKaufmann AMJungreis CAet al: Effect of transluminal angioplasty on cerebral blood flow in the management of symptomatic vasospasm following aneurysmal subarachnoid hemorrhage. J Neurosurg 86:8308391997J Neurosurg 86:

5.

Fisher CMKistler JPDavis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:191980Neurosurgery 6:

6.

Fortune JBFeustel PJWeigle CGet al: Continuous measurement of jugular venous oxygen saturation in response to transient elevations of blood pressure in head-injured patients. J Neurosurg 80:4614681994J Neurosurg 80:

7.

Gibbs ELLennox WGNims LFet al: Arterial and cerebral venous blood. Arterial-venous difference in man. J Biol Chem 144:3253321942J Biol Chem 144:

8.

Haley EC JrKassell NFTorner JCet al: The International Cooperative Study on the Timing of Aneurysm Surgery: the North American experience. Stroke 23:2052141992Stroke 23:

9.

Heros RCZervas NTVarsos V: Cerebral vasospasm after subarachnoid hemorrhage: an update. Ann Neurol 14:5996081983Ann Neurol 14:

10.

Higashida RTHalbach VVCahan LDet al: Transluminal angioplasty for treatment of intracranial arterial vasospasm. J Neurosurg 71:6486531989J Neurosurg 71:

11.

Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968J Neurosurg 28:

12.

Jakobsen MEnevoldsen E: Retrograde catheterization of the right internal jugular vein for serial measurements of cerebral venous oxygen content. J Cereb Blood Flow Metab 9:7177201989J Cereb Blood Flow Metab 9:

13.

Jennett BTeasdale G: Aspects of coma after severe head injury. Lancet 2:8788811977Lancet 2:

14.

Kaku YYonekawa YTsukahara Tet al: Supraselective intraarterial infusion of papaverine for the treatment of cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg 77:8428471992J Neurosurg 77:

15.

Kassell NFHelm GSimmons Net al: Treatment of cerebral vasospasm with intra-arterial papaverine. J Neurosurg 77:8488521992J Neurosurg 77:

16.

Kassell NFPeerless SJDurward QJet al: Treatment of ischemic deficits from vasospasm with intravascular volume expansion and induced arterial hypertension. Neurosurgery 11:3373431982Neurosurgery 11:

17.

Kety SSSchmidt CF: The determination of cerebral blood flow in man by the use of nitrous oxide in low concentrations. Am J Physiol 143:53661945Am J Physiol 143:

18.

Kety SSSchmidt CF: The nitrous oxide method for the quantitative determination of cerebral blood flow in man: theory, procedure, and normal values. J Clin Invest 27:4764831948J Clin Invest 27:

19.

Lassen NA: The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet 2:111311151966Lassen NA: The luxury-perfusion syndrome and its possible relation to acute metabolic acidosis localised within the brain. Lancet 2:

20.

Longstreth WT JrNelson LMKoepsell TDet al: Clinical course of spontaneous subarachnoid hemorrhage: a population-based study in King County, Washington. Neurology 43:7127181993Neurology 43:

21.

Luer MSDujovny MSlavin KVet al: Regional cerebral oxygen saturation during intra-arterial papaverine therapy for vasospasm: case report. Neurosurgery 37:103310361995Neurosurgery 37:

22.

Macdonald RLZhang JSima Bet al: Papaverine-sensitive vasospasm and arterial contractility and compliance after subarachnoid hemorrhage in dogs. Neurosurgery 37:9629681995Neurosurgery 37:

23.

Morgan MHalcrow SSorby Wet al: Outcome of aneurysmal subarachnoid haemorrhage following the introduction of papaverine angioplasty. J Clin Neurosci 3:1391421996J Clin Neurosci 3:

24.

Nemoto EMHoff JTSeveringhaus JW: Lactate uptake and metabolism by brain during hyperlactatemia and hypoglycemia. Stroke 5:48531974Stroke 5:

25.

Newell DWEskridge JMMayberg MRet al: Angioplasty for the treatment of symptomatic vasospasm following subarachnoid hemorrhage. J Neurosurg 71:6546601989J Neurosurg 71:

26.

Origatano TCWascher TMReichman OHet al: Sustained increased cerebral blood flow with prophylactic hypertensive, hypervolemic hemodilution (“Triple-H Therapy”) after subarachnoid hemorrhage. Neurosurgery 27:7297401990Neurosurgery 27:

27.

Polin RApperson-Hansen CGerman Pet al: Intraarterial papaverine for the treatment of symptomatic cerebral vasospasm. J Neurosurg 86:369A1997 (Abstract)J Neurosurg 86:

28.

Raichle MEGrubb RL JrGado MHet al: Correlation between regional cerebral blood flow and oxidative metabolism. In vivo studies in man. Arch Neurol 33:5235261976In vivo studies in man. Arch Neurol 33:

29.

Rehncrona SRosén ISiesjö BK: Brain lactic acidosis and ischemic cell damage: 1. Biochemistry and neurophysiology. J Cereb Blood Flow Metab 1:2973111981J Cereb Blood Flow Metab 1:

30.

Robertson CSGrossman RGGoodman CJet al: The predictive value of cerebral anaerobic metabolism with cerebral infarction after head injury. J Neurosurg 67:3613681987J Neurosurg 67:

31.

Robertson CSNarayan RKGokaslan ZLet al: Cerebral arteriovenous oxygen difference as an estimate of cerebral blood flow in comatose patients. J Neurosurg 70:2222301989J Neurosurg 70:

32.

Sheinberg MKanter MJRobertson CSet al: Continuous monitoring of jugular venous oxygen saturation in head-injured patients. J Neurosurg 76:2122171992J Neurosurg 76:

33.

Tsukahara TYonekawa YYamamoto Met al: The endothelium-dependent response of human cerebral arteries and its changes after subarachnoid hemorrhageSano KTakakura KKassell NFet al (eds): Cerebral Vasospasm. Tokyo: University of Tokyo Press1990227230Cerebral Vasospasm.

34.

Wise RJSBernardi SFrackowiak RSJet al: Serial observations on the pathophysiology of acute stroke. The transition from ischaemia to infarction as reflected in regional oxygen extraction. Brain 106:1972221983Brain 106:

35.

Zubkov YNNikiforov BMShustin VA: Balloon catheter technique for dilatation of constricted cerebral arteries after aneurysmal SAH. Acta Neurochir 70:65791984Acta Neurochir 70:

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