High-dose intra-arterial verapamil for the treatment of cerebral vasospasm after subarachnoid hemorrhage: prolonged effects on hemodynamic parameters and brain metabolism.
BACKGROUND
Studies attempting to establish the safety and efficacy of standard and high-dose intra-arterial infusions of calcium channel blockers for treatment of cerebral vasospasm have focused on hemodynamic changes during the angiographic procedure.


OBJECTIVE
To evaluate longer-term drug effects over the hours following infusion and the effects on brain tissue oxygen tension or cerebral metabolism.


METHODS
We studied 11 patients with poor-grade aneurysmal subarachnoid hemorrhages who underwent multimodality brain monitoring and angiography with infusion of high-dose intra-arterial verapamil (≥15 mg total dose). Hourly intracerebral microdialysis measurements and continuously recorded mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and Pbto₂ were analyzed for 6 hours before and 12 hours following treatment.


RESULTS
A median dose of 23 mg (range, 15-55 mg) of intra-arterial verapamil was given. Compared with baseline values, reductions in CPP and MAP were maximal at 3 hours postangiography (from 105 ± 13 mm Hg to 95 ± 15 mm Hg and from 116 ± 12 mm Hg to 106 ± 16 mm Hg, P < .01) and persisted for up to 6 hours (P < .04); increases in vasopressor therapy were required in 8 procedures (53%). ICP significantly increased during the first 3 hours post angiography (P < .03). Brain glucose increased by 33% by hour 9 (P < .001). There were no significant changes in Pbto₂ or the lactate/pyruvate ratio.


CONCLUSIONS
High-dose intra-arterial verapamil causes increases in ICP and reductions in CPP, followed by an increase in brain glucose levels, without altering brain oxygen tension or oxidative metabolism. Patients undergoing high-dose intra-arterial verapamil therapy warrant close hemodynamic and ICP monitoring for at least 12 hours following treatment.
Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA. rms2130@columbia.edu
R Morgan
RM
Stuart
Raimund
R
Helbok
Pedro
P
Kurtz
Michael
M
Schmidt
Luis
L
Fernandez
Kiwon
K
Lee
Neeraj
N
Badjatia
Stephan A
SA
Mayer
Sean
S
Lavine
Philip
P
Meyers
E Sander
ES
Connolly
Jan
J
Claassen
D000328:Adult; D001794:Blood Pressure; D001921:Brain / Q000187:drug effects* / Q000378:metabolism; D002560:Cerebrovascular Circulation / Q000187:drug effects; D005260:Female; D006439:Hemodynamics / Q000187:drug effects*; D006801:Humans; D007261:Infusions, Intra-Arterial; D008297:Male; D017551:Microdialysis; D008875:Middle Aged; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D014665:Vasodilator Agents / Q000008:administration & dosage*; D020301:Vasospasm, Intracranial / Q000188:drug therapy* / Q000209:etiology; D014700:Verapamil / Q000008:administration & dosage*
D014665:Vasodilator Agents; D014700:Verapamil