Endovascular treatment of cerebral vasospasm: Transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine

Cerebral vasospasm is still one of the leading causes of morbidity and mortality from subarachnoid hemorrhage. Vasospasm refractory to medical management can be treated with enclovascular therapies, such as transluminal balloon angioplasty or infusion of intra-arterial vasodilating agents. In our review of clinical series reported in the English language literature, transluminal balloon angioplasty produced clinical improvement in 62% of patients, significantly improved mean transcranial Doppler (TCD) velocities (P < .05), significantly improved cerebral blood flow (CBF) in 85% of patients as studied by 133 Xenon techniques and serial single photon emission computerized tomography, and was associated with 5.0% complications and 1.1% vessel rupture. Intra-arterial papaverine therapy produced clinical improvement in 43% of patients but only transiently, requiring multiple treatment sessions (1.7 treatments per patient); significantly improved mean TCD velocities (P < .01) but only for less than 48 hours; improved CBF in 60% of patients but only for less than 12 hours; and was associated with increases in intracranial pressure and 9.9% complications. Intra-arterial nicardipine therapy produced clinical improvement in 42% of patients, significantly improved mean TCD velocities (P < .001) for 4 days, and was associated with no complications in our small series. We have adopted a treatment protocol at our institution of transluminal balloon angioplasty and intra-arterial nicardipine therapy as the endovascular treatments for medically refractory cerebral vasospasm.