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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    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.



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