Continuous intra-arterial infusion of verapamil for treatment of severe vasospasm after subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Options are limited for treating vasospasm refractory to medical therapy. We present a patient with SAH and refractory vasospasm. After coil embolization of the aneurysm and initial near complete improvement, the patient developed severe DCI causing coma. Medical therapy failed and angiography showed severe vasospasm complicated by chronic occlusion of distal left ICA. Balloon angioplasty of proximal right ICA was attempted but failed, as a micro wire could not be advanced into the distal ICA and proximal ACA, MCA, and basilar arteries. Intra-arterial verapamil injection produced transient improvement but angioplasty could not be performed. Due to severe bilateral cerebral hypoperfusion, continuous intra-arterial verapamil was infused using micro-catheters placed in the right ICA and vertebral artery. After 22 h there was significant improvement in caliber of both vessels and perfusion in both hemispheres without complications.