Intraarterial Therapy

Intra-arterial therapy, including papaverine, verapamil, and angioplasty, has become a regular part of the arsenal of therapeutics to counteract vasospasm. In the first reported use of intra-arterial papaverine in 1992, 34 of 37 targeted vascular territories were successfully dilated and 8 out of 10 patients showed neurologic improvement (19). The prospectively collected database of the North American Trial of Tirilazad for Aneurysmal SAH was used to compare 31 patients treated with intra-arterial papaverine with matched patients (according to degree of vasospasm and Glasgow Coma Scale scores) who received only medical management (20). Despite the early report of angiographic improvement, no statistical difference was found in the three-month Glasgow Outcome Scale (GOS) scores between the groups. These trials, although not randomized, demonstrate the importance of selecting appropriate endpoints in evaluating the efficacy of a new treatment modality. Although papaverine indeed dilates spastic cerebral vessels, these studies suggest that the dilation is not sustained and does not alter long-term outcomes. Current interest surrounds the benefits of intra-arterial verapamil (which preliminarily results in both angiographic and clinical improvement), although this has not yet been assessed in a prospective manner (21).

Angioplasty consists of physically dilating constricted vessels with a balloon that has been placed within the lumen of the artery (via femoral cannulation). As a follow-up to a number of reports that angioplasty successfully dilates vessels, researchers investigated whether this intervention affected outcomes (22). Using a prospectively collected database, they compared 38 patients treated with angioplasty with 38 matched controls and found no significant difference in GOS scores at three months of follow-up. Despite its lack of observed clinical effect (which might have been masked by a small sample size), most institutions continue to use angioplasty regularly, as few other alternatives exist. Some have reported an interest in prophylactic balloon angioplasty (for which a pilot study was reported with excellent outcomes), but a formal clinical trial has not yet been reported (23 ).

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