PARADOXICAL AGGRAVATION OF VASOSPASM WITH PAPAVERINE INFUSION FOLLOWING ANEURYSMAL SUBARACHNOID HEMORRHAGE - CASE-REPORT

Reports of intraarterial papaverine infusion as treatment for cerebral vasospasm are few and documented complications are uncommon. The auth ors report the case of a patient with paradoxical aggravation of cereb ral arterial nan owing during selective intraarterial papaverine infus ion intended to treat vasospasm following aneurysmal subarachnoid hemo rrhage (SAH). A 48-year-old man presented to the authors' service with symptomatic vasospasm 10 days after experiencing an SAH. The ruptured anterior communicating artery aneurysm was surgically obliterated the following day, and thereafter maximum hypervolemic and hypertensive t herapies were used. However, the patient remained lethargic, and a sta ble xenon-computerized tomography (CT) cerebral blood flow (CBF) study revealed CBF to be 15 cc/100 g/minute in the left anterior cerebral a rtery (ACA) and 25 cc/100 g/minute in the right ACA territories. Cereb ral arteriography demonstrated diffuse severe left ACA and mild left m iddle cerebral artery (MCA) vasospasm. In response intraartereial papa verine was infused into the internal carotid artery just proximal to t he ophthalmic artery. During the infusion the patient became aphasic a nd exhibited right hemiplegia. Arteriography pet-formed immediately af ter the intraarterial papaverine infusion revealed diffuse exacerbatio n of vasospasm in the distal ACA and MCA territories. A repeat xenon-C T CBF study showed that CBF in the left ACA and the MCA had drasticall y decreased (2 cc/100 g/minute and 10 cc/100 g/minute, respectively). Despite aggressive management, infarction ultimately developed. This i s the first clinical case to illustrate a paradoxical effect of intraa rterial papaverine treatment for vasospasm following aneurysmal SAH. T he possible mechanisms of this paradoxical response and potential ther apeutic reactions are reviewed.