Technical considerations on intra-arterial papaverine hydrochloride for cerebral vasospasm

Abstract

Intra-arterial infusion of papaverine hydrochloride for subarachnoid hemorrhage-induced cerebral vasospasm has become an adjunctive endovascular therapy along with cerebral angioplasty. Our knowledge concerning the mechanism of action, method of administration and potential side effects of this therapeutic alternative are reviewed.

Facial Nerve Palsy After Intracisternal Papaverine Application During Aneurysm Surgery

“…6,18) High-dose papaverine can form a crystalline precipitate with components of human serum and may cause microembolic-related ischemic events, but this consideration appears to be only relevant to intraarterial papaverine administration. 15) Although we cannot clearly establish a cause-andeffect relationship, we suggest that the clinical and electrophysiological course of this case is striking enough to support the previous report that topical papaverine application can lead to transient facial nerve dysfunction.…”

“…4,10,[15][16][17] As with intracisternal application, all side effects were transient and reversible within 24 hours. Papaverine (6,7-dimethoxy-1-vera-trylisoquinoline) is an alkaloid extracted from the unripe seed capsules of the poppy plant, Papaver somniferum.…”

“…9) Intraarterial papaverine administration during arteriography has been used to prevent and reverse cerebral vasospasm after aneurysmal subarachnoid hemorrhage or resection of arteriovenous malformations. 1,14,15,19) Intraoperative topical, i.e., intracisternal papaverine application has been used to prevent vasospasm which can be caused by both intraoperative arterial manipulation and subarachnoid hemorrhage. 8,20) Topical papaverine is also used in non-neurosurgical operations in which vessel manipulation may induce vascular spasm, such as infant renal surgery.…”

“…7) Transient ipsilateral pupillary dilation (mydriasis) with pupillary areflexia after intracisternal and intraarterial papaverine application is a common benign side effect. 3,10,15,21) Papaverine is commonly used today and this mydriatic effect is well known so this is no longer reported. High-dose papaverine (240 mg) is used in our center to prevent mechanical vasospasm and the occasional case of delayed spasm after clipping of unruptured aneurysms.…”

Treatment Options for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

“…Papaverine is the most widely studied IA vasodilator. The administration of papaverine is associated with short-lived (roughly 3 h) effects on both vessel caliber and CBF, and multiple side effects, including brainstem depression, elevated intracranial pressure, seizures, hypotension, and occasionally paradoxical worsening of vasospasm [68,69]. Intracranial hypertension occurs in ≤42% of cases and may be associated with death and poor outcome [70][71][72][73].…”