Reversal of radiographically impending stroke with multiple intraarterial papaverine infusions in severe diffuse cerebral vasospasm induced by subarachnoid hemorrhage.
BACKGROUND
Selective intraarterial infusion of papaverine is used in the treatment of symptomatic cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage (SAH). Delays in instituting therapy for vasospasm can lead to irreversible cerebral infarction and a devastating outcome. Endovascular papaverine treatment of vasospasm in the presence of low-attenuation lesions on computed tomography (CT) is controversial, because of the fear of reperfusion hemorrhage in completed infarcts.


METHODS
Two patients with aneurysmal SAH who subsequently developed severe diffuse vasospasm were identified. In both patients, large areas of low-attenuation change suggesting impending cerebral infarction were seen on CT scans. The patients received multiple infusions of intraarterial papaverine in an effort to treat vasospasm refractory to medical management.


RESULTS
After multiple intermittent administrations of papaverine, which initially appeared to increase the low-attenuation changes, there was dramatic reversal of the radiographic findings. There was also improvement in circulation time, transcranial Doppler velocities, and clinical outcome.


CONCLUSIONS
These findings suggest that in some patients, intraarterial infusions of papaverine initiated in the earliest stages of ischemia may exacerbate the radiographic appearance of low-attenuation changes, but may ultimately reverse the evolution of cerebral infarction.
Liu
J K
JK
Department of Neurosurgery, New York Medical College, Valhalla, New York 10595, USA.
Tenner
M S
MS
Oestreich
H M
HM
Couldwell
W T
WT
D000328:Adult; D002545:Brain Ischemia / Q000188:drug therapy / Q000209:etiology*; D005260:Female; D006801:Humans; D007261:Infusions, Intra-Arterial; D008297:Male; D010208:Papaverine / Q000008:administration & dosage / Q000494:pharmacology*; D020521:Stroke / Q000209:etiology / Q000517:prevention & control*; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D014057:Tomography, X-Ray Computed; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000494:pharmacology*; D020301:Vasospasm, Intracranial / Q000150:complications / Q000188:drug therapy* / Q000473:pathology
D014665:Vasodilator Agents; D010208:Papaverine