High-dose intraarterial verapamil in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Abstract

This study indicates that high-dose intraarterial verapamil may be used to treat cerebral vasospasm without compromising hemodynamic stability or increasing ICP.

Improvement in Angiographic Cerebral Vasospasm after Intra-Arterial Verapamil Administration

“…In a study using lower doses of verapamil, Feng et al 7 reported statistically significant decreases in MAP of 3.8 Ϯ 1.0% at 10 minutes after treatment and 1.7 Ϯ 1.1% at 20 minutes after treatment. In a study using higher doses of verapamil than those in the current study, Keuskamp et al 8 reported qualitative transient decreases in heart rate and/or blood pressure in some of their patients lasting, at most, 5 minutes with no episodes of hypotension or new bradycardia. Some of the decreases in MAP were greater than 10 mm Hg, but specific measurements were not given.…”

“…Other studies have reported changes in gross neurologic status in treated patients. [7][8][9][10]17 Those parameters were outside the scope of the current study. In the absence of a control patient population, those data may be of limited value.…”

“…Feng et al 7 used an average of 2 mg per vessel for a total of 3.1 Ϯ 0.3 mg per procedure. The highest dose used in a single vessel was 8 mg. Keuskamp et al 8 used much higher doses at 41 Ϯ 29 mg per procedure. The duration of action of a pulsed dose of locally high-concentration intra-arterial verapamil is likely in the range of several hours, and repeat treatment may sometimes be required for ongoing optimal clinical effect.…”

“…One of the studies assigned subjective grades of angiographic vasospasm rather than applying specific measurements. 8 Another study reported only binary results in which angiographic vasospasm was described as Ͼ50% before treatment in all cases, and treatment resulting in residual vasospasm of any degree Ͻ50% was reported as "completely effective." 10 The diagnostic method of grading angiographic vasospasm by eye has been found to be unreliable, and clear-cut definitions of vessel stenosis are essential.…”

“…6 Preliminary studies of the effects of intra-arterial verapamil on angiographic vasospasm have yielded mixed and often poorly quantified results. [7][8][9][10] In 1 quantitative case series by Mazumdar et al 9 using blinded reviewers, there was no statistically significant change in the diameters of vasospastic cerebral arteries after treatment. Three other case series reported increased diameters of treated vasospastic arteries, but these studies did not use blinded reviewers.…”