Neuroradiology ~ Papaverine
Therapy for Vasospasm
Intra-arterial Papaverine Therapy for Vasospasm: Does it Work?
Key Words: subarachnoid
hemorrhage, vasospasm, papaverine
Interventional Neuroradiology service at Massachusetts General
and the MGH Brain Aneurysm & AVM Center.
Objectives: Cerebral vasospasm following aneurysmal subarachnoid
hemorrhage remains a significant problem among patients surviving
aneurysm rupture. Intra-arterial papaverine infusion has been shown
to have angiographic efficacy in relieving spasm and is presumed to
prevent new strokes among these patients. The latter is unproven.
The purpose of our study was to determine the CT incidence of vasospasm
induced stroke following the initiation of intra-arterial papaverine
Methods: We reviewed the clinical,
angiographic and CT data of all patients treated with intra-arterial
papaverine therapy for cerebral vasospasm following aneurysmal subarachnoid
hemorrhage between 12/93 and 6/97. All patients failed a trial of
hemodynamic augmentation prior to consideration of papaverine therapy.
Infusion was performed using microcatheter techniques and an infusion
protocol similar that published previously. The numbers of procedures
and of catheter infusion positions and the incidence of complications
were recorded. Pre-treatment and long term follow-up head CTs were
compared for the presence of new strokes.
Results: 35 patients were treated
in 86 procedures (2.5/pt) using a total of 125 catheter positions
(3.6/pt, 1.5/procedure). Two additional patients were excluded because
pre- and post-treatment CTs were unavailable. The dose varied between
50 mg and 300 mg per catheter position. 4 patients underwent balloon
angioplasty for spasm refractory to papaverine based on angiography.
14 patients (40%) developed new strokes following initiation of
papaverine treatment, 21 (60%) did not. There were 5 complications
related to papaverine therapy: 1 embolus resulting in a stroke and
4 dissections two of which contributed to the development of stroke.
That is, the symptomatic complication rate associated with papaverine
infusion was 3/35 = 8.6%.
Conclusions: A significant
minority of patients treated with intra-arterial papaverine for
cerebral vasospasm develop new strokes. Better therapies for this
dreaded complication of subarachnoid hemorrhage are needed.