Clyde B L, Firlik A D, Kaufmann A M, Spearman M P, Yonas H
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania 15213, USA.
J Neurosurg. 1996 Apr;84(4):690-5. doi: 10.3171/jns.1996.84.4.0690.
Reports of intraarterial papaverine infusion as treatment for cerebral vasospasm are few and documented complications are uncommon. The authors report the case of a patient with paradoxical aggravation of cerebral arterial narrowing during selective intraarterial papaverine infusion intended to treat vasospasm following aneurysmal subarachnoid hemorrhage (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 therapies were used. However, the patient remained lethargic, and a stable xenon-computerized tomography (CT) cerebral blood flow (CBF) study revealed CBF to be 15 cc/100 g/minute in the left anterior cerebral artery (ACA) and 25 cc/100 g/minute in the right ACA territories. Cerebral arteriography demonstrated diffuse severe left ACA and mild left middle cerebral artery (MCA) vasospasm. In response intraarterial papaverine was infused into the internal carotid artery just proximal to the ophthalmic artery. During the infusion the patient became aphasic and exhibited right hemiplegia. Arteriography performed immediately after the intraarterial papaverine infusion revealed diffuse exacerbation of vasospasm in the distal ACA and MCA territories. A repeat xenon-CT CBF study showed that CBF in the left ACA and the MCA had drastically decreased (2 cc/100 g/minute and 10 cc/100 g/minute, respectively). Despite aggressive management, infarction ultimately developed. This is the first clinical case to illustrate a paradoxical effect of intraarterial papaverine treatment for vasospasm following aneurysmal SAH. The possible mechanisms of this paradoxical response and potential therapeutic reactions are reviewed.
关于动脉内注入罂粟碱治疗脑血管痉挛的报道较少，且文献记载的并发症并不常见。作者报告了1例在选择性动脉内注入罂粟碱治疗动脉瘤性蛛网膜下腔出血（SAH）后血管痉挛期间出现脑动脉狭窄反常加重的患者。一名48岁男性在发生SAH后10天因症状性血管痉挛就诊于作者所在科室。次日，破裂的前交通动脉瘤接受了手术夹闭，此后采用了最大程度的扩容和高血压疗法。然而，患者仍处于嗜睡状态，一项稳定的氙计算机断层扫描（CT）脑血流（CBF）研究显示，左侧大脑前动脉（ACA）区域的CBF为15 cc/100 g/分钟，右侧ACA区域为25 cc/100 g/分钟。脑血管造影显示左侧ACA弥漫性重度痉挛及左侧大脑中动脉（MCA）轻度痉挛。作为应对措施，在眼动脉近端的颈内动脉内注入了罂粟碱。注入过程中，患者出现失语并表现为右侧偏瘫。动脉内注入罂粟碱后立即进行的血管造影显示，ACA远端和MCA区域的血管痉挛弥漫性加重。重复的氙-CT CBF研究显示，左侧ACA和MCA的CBF急剧下降（分别为2 cc/100 g/分钟和10 cc/100 g/分钟）。尽管进行了积极治疗，最终仍发生了梗死。这是首例说明动脉内罂粟碱治疗动脉瘤性SAH后血管痉挛出现反常效应的临床病例。本文对这种反常反应的可能机制及潜在治疗反应进行了综述。
