Intra-arterial papaverine in the management of cerebral vasospasm following subarachnoid haemorrhage.

Between July 1992 and January 1993 a prospective pilot study of the efficacy of intra-arterial papaverine in the management of clinically significant angiographically confirmed cerebral vasospasm arising as a consequence of aneurysmal subarachnoid haemorrhage was conducted. During this period 40 patients were managed with aneurysmal subarachnoid haemorrhage. All patients were treated with nimodipine from day of admission and carefully monitored in the neurosurgical intensive care unit. 11 of the 40 patients subsequently developed clinically significant angiographically confirmed cerebral vasospasm and underwent angiography with selective internal carotid or vertebral artery injection of papaverine in 12 to 40 mg boluses to a maximum of 450 mg. A good angiographic response was seen in all cases. Two patients underwent repeat procedures, in one case twice. Overall clinical outcome was good in 7 cases, moderate disability in 2 cases, severe disability in 1 case and death in 1 case. In patients who underwent the procedure in less than 4 hours from the onset of their deficits (n=8) a good outcome was seen to occur in 7 patients with one patient sustaining a moderate deficit. Complications from the procedure were seizures in 3 patients and a momentary locked-in-syndrome in one case. All complications were seen with a fast bolus of the higher volume papaverine and have not occurred with a slow infusion of the lower dose boluses. None of the patients developing these complications had them recur outside the angiogram suite. Our conclusion is that this form of treatment supplements the therapeutic regimens now available in the management of cerebral vasospasm.