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Li Z, Tremble SM, Cipolla MJ. Implications for understanding ischemic stroke as a sexually dimorphic disease: the role of pial collateral circulations. Am J Physiol Heart Circ Physiol 2018; 315:H1703-H1712. [PMID: 30239233 DOI: 10.1152/ajpheart.00402.2018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
We investigated structural and functional differences in primary and pial collateral circulations in adult normotensive male and female Wistar rats. Male ( n = 10) and female ( n = 7) rats were subjected to middle cerebral artery (MCA) occlusion and changes in relative cerebral blood flow in MCA and pial collateral territories were measured by multisite laser-Doppler flowmetry. Rats were then transcardially perfused with a mixture of carbon black and latex, perfusion fixed, and imaged to compare primary and pial collateral structure between male ( n = 4) and female ( n = 3) rats, including lumen diameters and number. To study pial collateral function, leptomeningeal anastomoses (LMAs) were isolated and pressurized from male ( n = 7) and female ( n = 6) rats. Myogenic tone and reactivity to pressure, vascular function to pharmacological activator, or inhibitor of ion channels was measured and compared. There was no difference between relative cerebral blood flow in both MCA and pial collateral territories during occlusion and reperfusion between groups. Compared with male LMAs, female LMAs had similar myogenic tone (24.0 ± 7.3% vs. 16.0 ± 3.7%, P > 0.05) and reactivity to increased pressure and similar vascular responses to vasoconstrictive and vasodilatory stimuli. Additionally, compared with female LMAs, male LMAs had similar numbers (21 ± 1 vs. 20 ± 2, P > 0.05) and diameters (30.5 ± 2.0 vs. 26.2 ± 0.6 μm, P > 0.05), and no sex difference was detected in the diameter of arterial segments of circle of Willis. Together, our data establish no sex difference of cerebral collateral structure or function, suggesting that the reduced severity of stroke outcome in female rats is not likely due to differences in the cerebral collateral circulation. NEW & NOTEWORTHY Our work compared the function of leptomeningeal anastomoses between male and female adult normotensive rats with no sex difference found. We also confirmed no sex difference in primary and pial collateral structure in Wistar rats. Our findings suggest that the reduced severity of stroke in premenopausal women and reproductively intact female rodents is not likely due to improved primary and pial collateral circulations.
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Affiliation(s)
- Zhaojin Li
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont
| | - Sarah M Tremble
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont
| | - Marilyn J Cipolla
- Department of Neurological Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont.,Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont Robert Larner College of Medicine , Burlington, Vermont.,Department of Pharmacology, University of Vermont Robert Larner College of Medicine , Burlington, Vermont
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Nolan MW, Marolf AJ, Ehrhart EJ, Rao S, Kraft SL, Engel S, Yoshikawa H, Golden AE, Wasserman TH, LaRue SM. Pudendal nerve and internal pudendal artery damage may contribute to radiation-induced erectile dysfunction. Int J Radiat Oncol Biol Phys 2015; 91:796-806. [PMID: 25752394 DOI: 10.1016/j.ijrobp.2014.12.025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE/OBJECTIVES Erectile dysfunction is common after radiation therapy for prostate cancer; yet, the etiopathology of radiation-induced erectile dysfunction (RI-ED) remains poorly understood. A novel animal model was developed to study RI-ED, wherein stereotactic body radiation therapy (SBRT) was used to irradiate the prostate, neurovascular bundles (NVB), and penile bulb (PB) of dogs. The purpose was to describe vascular and neurogenic injuries after the irradiation of only the NVB or the PB, and after irradiation of all 3 sites (prostate, NVB, and PB) with varying doses of radiation. METHODS AND MATERIALS Dogs were treated with 50, 40, or 30 Gy to the prostate, NVB, and PB, or 50 Gy to either the NVB or the PB, by 5-fraction SBRT. Electrophysiologic studies of the pudendal nerve and bulbospongiosus muscles and ultrasound studies of pelvic perfusion were performed before and after SBRT. The results of these bioassays were correlated with histopathologic changes. RESULTS SBRT caused slowing of the systolic rise time, which corresponded to decreased arterial patency. Alterations in the response of the internal pudendal artery to vasoactive drugs were observed, wherein SBRT caused a paradoxical response to papaverine, slowing the systolic rise time after 40 and 50 Gy; these changes appeared to have some dose dependency. The neurofilament content of penile nerves was also decreased at high doses and was more profound when the PB was irradiated than when the NVB was irradiated. These findings are coincident with slowing of motor nerve conduction velocities in the pudendal nerve after SBRT. CONCLUSIONS This is the first report in which prostatic irradiation was shown to cause morphologic arterial damage that was coincident with altered internal pudendal arterial tone, and in which decreased motor function in the pudendal nerve was attributed to axonal degeneration and loss. Further investigation of the role played by damage to these structures in RI-ED is warranted.
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Affiliation(s)
- Michael W Nolan
- Department of Clinical Sciences, and Center for Comparative Medicine and Translational Research, North Carolina State University, Raleigh, North Carolina; Department of Environmental and Radiologic Health Sciences, Colorado State University, Fort Collins, Colorado.
| | - Angela J Marolf
- Department of Environmental and Radiologic Health Sciences, Colorado State University, Fort Collins, Colorado
| | - E J Ehrhart
- Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, Colorado
| | - Sangeeta Rao
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
| | - Susan L Kraft
- Department of Environmental and Radiologic Health Sciences, Colorado State University, Fort Collins, Colorado
| | - Stephanie Engel
- Department of Clinical Sciences, Colorado State University, Fort Collins, Colorado
| | - Hiroto Yoshikawa
- Department of Environmental and Radiologic Health Sciences, Colorado State University, Fort Collins, Colorado
| | - Anne E Golden
- Department of Environmental and Radiologic Health Sciences, Colorado State University, Fort Collins, Colorado
| | - Todd H Wasserman
- Department of Radiation Oncology, Washington University, St. Louis, Missouri
| | - Susan M LaRue
- Department of Environmental and Radiologic Health Sciences, Colorado State University, Fort Collins, Colorado
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Zhu W, Liu S, Zhao J, Liu S, Jiang S, Li B, Yang H, Fan C, Cui W. Highly flexible and rapidly degradable papaverine-loaded electrospun fibrous membranes for preventing vasospasm and repairing vascular tissue. Acta Biomater 2014; 10:3018-28. [PMID: 24704697 DOI: 10.1016/j.actbio.2014.03.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 02/21/2014] [Accepted: 03/20/2014] [Indexed: 10/25/2022]
Abstract
Vasospasm is a common post-operative complication after vascular anastomosis. Currently, the main treatment is a local injection of antispasmodic drugs. However, this method has a high rate of relapse and is subject to a large degree of individual variation, and repeated injections cause additional pain for patients. In this study, we developed highly flexible and rapidly degradable papaverine-loaded electrospun fibrous membranes to be wrapped around vascular suturing to prevent vasospasm. Poly-l-lactic acid/polyethylene glycol (PLLA/PEG) electrospun fibers containing papaverine maintained a high degree of flexibility and could withstand any folding, and are therefore suitable for wrapping vascular suturing. A rapid release of papaverine, between 2 and 7 days, was achieved by adjusting the proportions of PEG and PLLA. PLLA electrospun fibers containing 40% PEG (PLLA-40%) could control drug release and polymer degradation most effectively during the first 2 weeks post-operation. Testing using an in vivo rabbit model showed that PLLA-40% fibrous membranes produced significant antispasmodic effect without observable inflammation or hyperplasia, and the fibrous membranes were ideally biodegradable, with no impact on regional blood flow, pressure, vessel diameter or surrounding tissue hyperplasia. Therefore, papaverine-loaded electrospun fibrous membranes show the potential to greatly reduce post-operative vasospasm and maintain regular vascular morphology during antispasmodic therapy.
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Kurata A, Suzuki S, Niki J, Ozawa H, Yamada M, Fujii K, Kan S, Kitahara T, Miyasaka Y, Ohmomo T. Endovascular surgery for ruptured aneurysms with vasospasm. Interv Neuroradiol 2007; 13 Suppl 1:48-52. [PMID: 20566076 DOI: 10.1177/15910199070130s105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Accepted: 01/15/2007] [Indexed: 11/17/2022] Open
Abstract
SUMMARY With the existence of vasospasm, it is recommended that direct clipping surgery for a ruptured aneurysm be delayed until its disappearance, but this may be associated with aneurysmal re-rupture resulting in a poor outcome for the patients. Indications for endovascular coil embolization in such cases are discussed. Since November in 2003, we have applied endovascular coil embolization in 11 consecutive patients with ruptured aneurysms and apparent vasospasm of the parent artery from two to 17 days (average: eight days) after initial subarachnoid hemorrhage. Three patients had aneurysmal re-rupture before treatment, but the other eight had only experienced the one episode of subarachnoid hemorrhage. With one exception, all endovascular procedures could be successfully performed, resulting in complete occlusion of aneurysms and remarkable dilatation of inserted spastic vessels without technical complications or aneurysmal re-rupture. For the one case of failure because of a tortuous artery, direct clipping surgery was performed after disappearance of vasospasm. Cerebral infarction occurred in four, but only one correlated with the distribution of catheterization, and neurological deficits had completely disappeared three months after the onset. This preliminary report concerning a small number of patients suggests that endovascular coil embolization is not contra-indicated for aneurysms with vasospasm requiring catheterization. A large study for confirmation is now warranted.
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Affiliation(s)
- A Kurata
- Departments of Neurosurgery, Radiology and Critical Care Medicine, Kitasato University School of Medicine, Kanagawa, Japan -
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Bright R, Steinberg GK, Mochly-Rosen D. DeltaPKC mediates microcerebrovascular dysfunction in acute ischemia and in chronic hypertensive stress in vivo. Brain Res 2007; 1144:146-55. [PMID: 17350602 PMCID: PMC3742377 DOI: 10.1016/j.brainres.2007.01.113] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 01/20/2007] [Accepted: 01/23/2007] [Indexed: 01/28/2023]
Abstract
Maintaining cerebrovascular function is a priority for reducing damage following acute ischemic events such as stroke, and under chronic stress in diseases such as hypertension. Ischemic episodes lead to endothelial cell damage, deleterious inflammatory responses, and altered neuronal and astrocyte regulation of vascular function. These, in turn, can lead to impaired cerebral blood flow and compromised blood-brain barrier function, promoting microvascular collapse, edema, hemorrhagic transformation, and worsened neurological recovery. Multiple studies demonstrate that protein kinase C (PKC), a widely expressed serine/threonine kinase, is involved in mediating arterial tone and microvascular function. However, there is no clear understanding about the role of individual PKC isozymes. We show that intraperitoneal injection of deltaV1-1-TAT(47-57) (0.2 mg/kg in 1 mL), an isozyme-specific peptide inhibitor of deltaPKC, improved microvascular pathology, increased the number of patent microvessels by 92% compared to control-treated animals, and increased cerebral blood flow by 26% following acute focal ischemia induced by middle cerebral artery occlusion in normotensive rats. In addition, acute delivery of deltaV1-1-TAT(47-57) in hypertensive Dahl rats increased cerebral blood flow by 12%, and sustained delivery deltaV1-1-TAT(47-57) (5 uL/h, 1 mM), reduced infarct size by 25% following an acute stroke induced by MCA occlusion for 90 min. Together, these findings demonstrate that deltaPKC is an important therapeutic target for protection of microvascular structure and function under both acute and chronic conditions of cerebrovascular stress.
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Affiliation(s)
- Rachel Bright
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary K. Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA, USA
| | - Daria Mochly-Rosen
- Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA, USA
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
- Corresponding author. Department of Chemical and Systems Biology, Stanford University School of Medicine, Stanford, CA 94305-5174, USA. Fax: +1 650 723 2253
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Liu JK, Tenner MS, Gottfried ON, Stevens EA, Rosenow JM, Madan N, MacDonald JD, Kestle JRW, Couldwell WT. Efficacy of multiple intraarterial papaverine infusions for improvement in cerebral circulation time in patients with recurrent cerebral vasospasm. J Neurosurg 2004; 100:414-21. [PMID: 15035276 DOI: 10.3171/jns.2004.100.3.0414] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebral vasospasm that is caused by aneurysmal subarachnoid hemorrhage and that is refractory to maximal medical management can be treated with selective intraarterial papaverine infusions. The effects of single papaverine treatments on cerebral circulation time are well known. The purpose of this study was to assess the efficacy of multiple, repeated papaverine infusions on the cerebral circulation time in patients with recurrent vasospasm. METHODS A retrospective study was conducted in 17 patients who received multiple intraarterial papaverine infusions in 91 carotid artery (CA) territories for the treatment of cerebral vasospasm. Cerebral circulation times were measured from the first angiographic image, in which peak contrast was seen above the supraclinoid internal CA, to the peak filling of cortical veins. Glasgow Outcome Scale (GOS) scores assessed 12 months after discharge were reviewed. Cerebral circulation times in 16 CA territories were measured in a control group of 11 patients. Seventeen patients received a total of 91 papaverine treatments. Prolonged cerebral circulation times improved after 90 (99%) of 91 papaverine treatments. The prepapaverine mean cerebral circulation time was 6.54 seconds (range 3.35-27 seconds) and the immediate postpapaverine mean cerebral circulation time was 4.19 seconds (range 2.1-12.6 seconds), an overall mean decrease of 2.35 seconds (36%, p < 0.001). Recurrent vasospasm reflected by prolonged cerebral circulation times continued to improve with subsequent papaverine infusions. Repeated infusions were just as successful quantitatively as the primary treatment (mean change 2.06 seconds). The mean cerebral circulation time in the control group was 5.21 seconds (range 4-6.8 seconds). In five patients a dramatic reversal of low-attenuation changes was detected on computerized tomography scans. The mean GOS score at 12 months after discharge was 3.4. CONCLUSIONS The preliminary results indicate that multiple intraarterial papaverine treatments consistently improve cerebral circulation times, even with repeated infusions in cases of recurrent vasospasm.
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Affiliation(s)
- James K Liu
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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Liu HM, Tu YK. The efficacy of papaverine administration by different routes for the treatment of experimental acute cerebral vasospasm. J Clin Neurosci 2002; 9:561-5. [PMID: 12383416 DOI: 10.1054/jocn.2001.1036] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the effect of papaverine (PPV) by different routes of administration for the treatment of experimental acute cerebral vasospasm. METHODS A rabbit model of acute cerebral vasospasm induced by autologous blood injected into the basilar and prepontine cistern was used. The PPV (2mg/kg) was injected either by an intravenous (IV), intra-arterial (IA), intra-cisternal (IC), or combination of intra-arterial and intra-cisternal (IA+IC) routes. Basilar artery diameters were measured before and after vasospasm was induced and after PPV treatment. RESULTS Induction of vasospasm reduced basilar artery diameters by more than 50% in all animals. Compared to artery diameters before vasospasm, diameters after PPV treatment via the IV route were only reduced by 0.5+/-4.7%. Other reductions in the diameter included 29.1+/-10.4%, about 1.8+/-3.1%, and about 26.7+/-8.4% in the IA, IC, and IA+IC groups, respectively. However, IA administration of PPV caused obvious side effects. CONCLUSION Intra-arterial application of the PPV was the most effective way to treat vasospasm in this study. The efficacy of IC route in our study did not confirm the results of prior study. The possibility of side effects of PPV via the IA route should be considered before clinical application.
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Affiliation(s)
- Hon-Man Liu
- Department of Medical Imaging, Hospital and Medical College, National Taiwan University, Taipei, Taiwan
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Andaluz N, Tomsick TA, Tew JM, van Loveren HR, Yeh HS, Zuccarello M. Indications for endovascular therapy for refractory vasospasm after aneurysmal subarachnoid hemorrhage: experience at the University of Cincinnati. SURGICAL NEUROLOGY 2002; 58:131-8; discussion 138. [PMID: 12453652 DOI: 10.1016/s0090-3019(02)00789-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Transluminal balloon angioplasty (TBA) and intra-arterial papaverine (IAP) appear to be valuable alternatives for the treatment of aneurysmal subarachnoid hemorrhage (SAH)-induced vasospasm refractory to maximal medical therapy. Although widely used, guiding principles for the implementation of TBA and IAP are not yet established. Based on our retrospective analysis, we define guidelines for endovascular therapy for refractory vasospasm based on our clinical results, adverse effects, and pattern of vasospasm. METHODS Medical records of 62 patients who experienced aneurysmal SAH-induced vasospasm refractory to hypervolemic, hypertensive, hyperdynamic therapy, and who were treated with IAP or TBA were reviewed. Fifty patients met the inclusion criteria for analysis. After careful scrutiny, two types of responses to endovascular treatment were identified. On the basis of that grouping, patients were divided into two groups according to the number of arterial segments involved, that is, monoterritorial and multiterritorial vasospasm. Multiple variables were analyzed. RESULTS Patients undergoing multiple endovascular procedures exhibited the worst outcomes. Patients in the monoterritorial group experienced a higher incidence of clinical improvement and better outcomes after endovascular treatment. Elevated intracranial pressure (ICP) and ICP-related deaths were more prominent in the multiterritorial group of patients. Sustained ICP elevation after administration of IAP was strongly associated with poor outcome in the multiterritorial group. CONCLUSIONS IAP is indicated as an early potential single-dose infusion in distal monoterritorial vasospasm, if angioplasty is impossible or unsafe. The use of IAP in bilateral diffuse vasospasm is discouraged because of the high susceptibility of these patients to develop elevated ICP. Multiple IAP infusions seem to have no significant impact on patient outcome. Balloon angioplasty seems to be indicated at an early juncture in patients with multiterritorial proximal vasospasm.
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Affiliation(s)
- Norberto Andaluz
- Department of Neurosurgery, The Neuroscience Institute, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267-0515, USA
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Abstract
Papaverine is a vasodilator commonly used in the treatment of vasospasmic diseases such as cerebral spasm associated with subarachnoid hemorrhage, and in the prevention of spasm of coronary artery bypass graft by intraluminal and/or extraluminal administration. In this study, we examined whether papaverine in the range of concentrations used clinically causes apoptosis of vascular endothelial and smooth muscle cells. Apoptotic cells were identified by morphological changes and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL) assay. In porcine coronary endothelial cells (EC) and rat aortic smooth muscle cells (SMC), papaverine at the concentration of 10(-3) M induced membrane blebbing within 1 hour of incubation. Nuclear condensation and fragmentation were found after 24 hours of treatment. The number of apoptotic cells stained with the TUNEL method was significantly higher in the EC and the SMC after 24 hours of incubation with papaverine at the concentrations of 10(-4) and 10(-3) M than their respective controls. Acidified saline solution (pH 4.8, as control for 10(-3) M papaverine hydrochloride) did not cause apoptosis in these cells. These results showed that papaverine could damage endothelial and smooth muscle cells by inducing changes which are associated with events leading to apoptosis. Since integrity of endothelial cells is critical for normal vascular function, vascular administration of papaverine for clinical use, especially at high concentrations (> or = 10(-4) M), should be re-considered.
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Affiliation(s)
- Y J Gao
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
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Joshi S, Hashimoto T, Ostapkovich N, Pile-Spellman J, Duong DH, Hacein-Bey L, Hacien-Bey L, Marshall RS, James DJ, Young WL. Effect of intracarotid papaverine on human cerebral blood flow and vascular resistance during acute hemispheric arterial hypotension. J Neurosurg Anesthesiol 2001; 13:146-51. [PMID: 11294457 DOI: 10.1097/00008506-200104000-00013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
This study assessed the feasibility of augmenting cerebral blood flow (CBF) and decreasing hemispheric cerebrovascular resistance (CVR) by intracarotid papaverine during acute cerebral hypotension. Awake patients (n = 10) undergoing transfemoral balloon occlusion of an internal carotid artery (ICA) with nitroprusside (SNP)-induced systemic hypotension (10% reduction of mean arterial pressure) were studied. We measured mean femoral artery pressure (MAP), mean distal ICA pressure (P(ica)), and CBF (intracarotid 133Xe) at two time points: before and after intracarotid papaverine infusion (1 or 7 mg/min). Two patients became symptomatic immediately after ICA occlusion and were excluded. One patient developed a focal seizure during papaverine infusion. In another, the occlusion balloon deflated prematurely. Of the remaining six patients, two of the three patients who received high-dose papaverine (7 mg/min) developed transient obtundation. The remaining three patients, who received low-dose papaverine (1 mg/min), did not develop any neurologic symptoms. There was a trend for intracarotid papaverine to increase hemispheric CBF by 36% (33 +/- 10 versus 45 +/- 22 ml x 100 g(-1) x min(-1), P = .084, n = 6); papaverine decreased CVR from 1.3 +/- 0.4 to 1.0 +/- 0.3 mm Hg x ml(-1) x 100 g(-1) x min(-1) (P = .049). There was no significant change in heart rate, MAP, or P(ica) during experimental protocol. Manipulation of CVR by intracarotid papaverine during acute hemispheric arterial hypotension appears to be feasible. Further studies are needed to establish safety and efficacy.
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Affiliation(s)
- S Joshi
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Arquilla B, Gupta R, Gernshiemer J, Fischer M. Acute arterial spasm in an extremity caused by inadvertent intra-arterial injection successfully treated in the emergency department. J Emerg Med 2000; 19:139-43. [PMID: 10903461 DOI: 10.1016/s0736-4679(00)00200-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We present a case of limb ischemia in a young man. For acute alcohol withdrawal, this patient was given chlordiazepoxide (Librium) through an angiocatheter inadvertently placed into a brachial arterial line. This caused severe spasm of the brachial artery and its branches. These findings were confirmed by angiography. Successful treatment occurred with intra-arterial papaverin.
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Affiliation(s)
- B Arquilla
- Department of Emergency Medicine, Our Lady of Mercy Medical Center, Bronx, NY, USA
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12
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Affiliation(s)
- T P Smith
- Department of Radiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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13
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Papaverine and Vasospasm. J Neurosurg 2000. [DOI: 10.3171/jns.2000.92.3.0509a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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14
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Papaverine and Vasospasm. J Neurosurg 2000. [DOI: 10.3171/jns.2000.92.3.0509b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Tsurushima H, Kamezaki T, Nagatomo Y, Hyodo A, Nose T. Complications associated with intraarterial administration of papaverine for vasospasm following subarachnoid hemorrhage--two case reports. Neurol Med Chir (Tokyo) 2000; 40:112-5. [PMID: 10786100 DOI: 10.2176/nmc.40.112] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Complications associated with intraarterial papaverine infusion occurred in two patients treated for vasospasm due to subarachnoid hemorrhage (SAH). A 42-year-old male with an anterior communicating artery aneurysm underwent craniotomy and aneurysm clipping. Five days after the SAH occurred, angiography demonstrated moderate vasospasm in spite of hypervolemic-hypertensive therapy. During papaverine infusion into the carotid artery, he suffered loss of consciousness due to a seizure for a few minutes. A 61-year-old female with a right internal carotid-posterior communicating artery aneurysm underwent clipping. Six days after the SAH occurred, angiography demonstrated severe vasospasm in spite of hypervolemic-hypertensive therapy. Angiography performed immediately after papaverine infusion into the carotid artery revealed exacerbation of the vasospasm. Finally she suffered cerebral infarction and died. Complications of intraarterial papaverine infusion are potentially dangerous. We recommend trial administration of papaverine with angiography and neurological examination before full dose infusion to avoid complications.
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Affiliation(s)
- H Tsurushima
- Department of Neurosurgery, Ibaraki Seinam Medical Center Hospital, Japan
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Firlik KS, Kaufmann AM, Firlik AD, Jungreis CA, Yonas H. Intra-arterial papaverine for the treatment of cerebral vasospasm following aneurysmal subarachnoid hemorrhage. SURGICAL NEUROLOGY 1999; 51:66-74. [PMID: 9952126 DOI: 10.1016/s0090-3019(97)00370-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Intra-arterial papaverine (IAP) has been described as a treatment for cerebral vasospasm refractory to standard therapy. METHODS We report a series of 15 consecutive patients with aneurysmal subarachnoid hemorrhage in which IAP was employed for the treatment of symptomatic vasospasm. All patients exhibited delayed ischemic neurologic deficits, focal cerebral hypoperfusion on stable xenon-enhanced computerized tomography cerebral blood flow studies, and angiographically defined arterial narrowing. Papaverine was infused into 32 arteries on 23 occasions. Six patients required multiple treatments between 1 and 8 days apart. In five instances, IAP was combined with angioplasty. RESULTS Angiographically defined vasospasm was at least partially reversed immediately following treatment on 18 of 23 occasions. The associated clinical improvement was major on 6 occasions, and either minor or none on 17. Post-treatment cerebral blood flow was assessed on 13 occasions and showed improvement in previously ischemic areas on six occasions and no improvement on seven. Complications were encountered on four occasions. Systemic hypotension and transient brain-stem depression were seen with vertebral artery infusions; a generalized seizure and paradoxical aggravation of vasospasm resulting in hemispheric infarction occurred with internal carotid artery infusions. CONCLUSIONS Intra-arterial papaverine resulted in reversal of arterial narrowing in the majority of cases (78%). However, this angiographic improvement was associated with cerebral blood flow augmentation in only 46% of cases analyzed, and major clinical improvement in 26%.
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Affiliation(s)
- K S Firlik
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pennsylvania, USA
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Polin RS, Hansen CA, German P, Chadduck JB, Kassell NF. Intra-arterially administered papaverine for the treatment of symptomatic cerebral vasospasm. Neurosurgery 1998; 42:1256-64; discussion 1264-7. [PMID: 9632183 DOI: 10.1097/00006123-199806000-00031] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE We examined the therapeutic benefits of intra-arterially administered papaverine for treatment of symptomatic cerebral vasospasm after subarachnoid hemorrhage (SAH). Recent advances in microcatheter technology have facilitated endovascular approaches to vessels experiencing vasospasm after SAH. However, despite numerous encouraging anecdotal reports, no rigorous examination of the efficacy of these procedures has been published. Intra-arterial infusion of papaverine has become part of the standard management of vasospasm at some centers. METHODS We examined a series of 31 patients undergoing papaverine infusion for the treatment of symptomatic vasospasm after SAH. The patients were a subgroup of the series enrolled in the North American Trial of Tirilizad for Aneurysmal Subarachnoid Hemorrhage. These individuals were matched with patients from the same trial who exhibited similar clinical characteristics (including the degree of vasospasm and the modified Glasgow Coma Scale scores measured at the time of admission and on the day of papaverine infusion) but received medical management alone for vasospasm. RESULTS Logistic regression analysis comparing these two groups showed no statistical difference in the 3-month Glasgow Outcome Scale scores between patients receiving papaverine and control subjects (58% favorable outcomes for control subjects versus 45% for patients receiving papaverine). CONCLUSION Although isolated series documenting clinical successes have prompted the increased use of papaverine as a treatment for vasospasm after SAH, this series suggests that, as it is currently being used, the drug does not provide added benefits, compared with medical treatment of vasospasm alone. This result does not preclude the possibility that alterations in the timing of or indications for drug treatment might produce beneficial effects.
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Affiliation(s)
- R S Polin
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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Polin RS, Kassell NF. Treatment of vasospasm. J Neurosurg 1998; 88:933. [PMID: 9576271 DOI: 10.3171/jns.1998.88.5.0933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sawada M, Hashimoto N, Tsukahara T, Nishi S, Kaku Y, Yoshimura S. Effectiveness of intra-arterially infused papaverine solutions of various concentrations for the treatment of cerebral vasospasm. Acta Neurochir (Wien) 1997; 139:706-11. [PMID: 9309284 DOI: 10.1007/bf01420042] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We evaluated the effect of intra-arterially infused papaverine solutions of various concentrations on cerebral vasospasm following subarachnoid haemorrhage. A total of 90 vascular territories in 46 patients with symptomatic cerebral vasospasm after subarachnoid haemorrhage were treated with intra-arterial infusions of papaverine. In all patients, papaverine was infused at the top of the internal carotid artery (ICA). Of the 90 vascular territories, 30 vascular territories in 14 patients were treated with an infusion of 0.1-0.2% (weight/volume) papaverine (Group 1), 30 vascular territories in 16 patients were treated with a 0.4% (w/v) papaverine infusion (Group 2), and 30 vascular territories in 16 patients were treated with an infusion of 0.8-2.0% (w/v) papaverine (Group 3). Among the three groups, we compared the vasodilatory effects of papaverine by assessing the angiographical and clinical improvements following the treatment. When 0.4% (w/v) papaverine was infused, 24 vascular territories (80%) were successfully dilated and 7 patients (44%) showed a marked reversal of neurological deficits due to vasospasm. Therefore, 80 mg/20 ml (0.4% (w/v)) papaverine infused over a 10-minute period proved to be a beneficial concentration. Transient focal neurological deficits due to the infusion of papaverine occurred in 1 Group 1 patient (7%), 1 Group 2 patient (6%), and 7 Group 3 patients (44%). Highly concentrated papaverine had a higher risk of temporary deterioration. In conclusion, the papaverine concentration of 0.4% (w/v) infused at the top of the ICA was a safe and adequate concentration for treating cerebral vasospasm.
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Affiliation(s)
- M Sawada
- Department of Neurosurgery, National Cardiovascular Centre, Osaka, Japan
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Terada T, Kinoshita Y, Yokote H, Tsuura M, Nakai K, Itakura T, Hyotani G, Kuriyama T, Naka Y, Kido T. The effect of endovascular therapy for cerebral arterial spasm, its limitation and pitfalls. Acta Neurochir (Wien) 1997; 139:227-34. [PMID: 9143589 DOI: 10.1007/bf01844756] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE The effect of endovascular treatment for vasospasm was investigated by analysing the results of patients treated in Wakayama City in 1994. MATERIALS AND METHODS Ninety nine patients with ruptured cerebral aneurysms, who survived more than one week and were treated in Wakayama City in 1994, were studied. Twenty five patients caused symptomatic vasospasm and 25 were treated by endovascular therapy, percutaneous transluminal angioplasty (PTA) and/or intra-arterial papaverine infusion (IAP). PTA was performed for proximal vasospasm which located in the main arterial trunk, such as ICA, M1, BA (n = 3). IAP was chosen for distal vasospasm which located mainly in the M2, A1, A2 (n = 12). PTA and/or IAP was performed for diffuse vasospasm which located in proximal and distal arteries (n = 10). RESULTS In the proximal vasospasm group, all patients were good to moderately disabled on the Glasgow outcome scale (GOS). In the distal vasospasm group, 8 patients were good to moderately disabled, and 4 patients were severely disabled. The overall results were as follows: 17 (68%), good to moderately disabled, 4 (16%), severely disabled, 4 (16%), dead. The morbidity and mortality rate was 8/25 (32%) in symptomatic spasm group. CONCLUSION PTA was very effective especially for proximal vasospasm, but IAP was not always effective for distal or diffuse vasospasm. Diffuse vasospasm revealed a high mortality rate in spite of the endovascular therapy.
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Affiliation(s)
- T Terada
- Department of Neurological Surgery, Wakayama Medical College, Japan
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Fergus A, Jin Y, Thai QA, Kassell NF, Lee KS. Tonic protein kinase C-mediated vasoconstriction is unmasked when nitric oxide synthase is inhibited in cerebral microvessels. Neuroscience 1996; 74:927-34. [PMID: 8884787 DOI: 10.1016/0306-4522(96)00158-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Recent evidence indicates that nitric oxide participates in the modulation of vascular tone in a variety of vascular beds, including the parenchymal microvasculature of the brain. The present study examined the role of protein kinase activity in the induction and maintenance of the contractile response when endogenous nitric oxide production is inhibited in parenchymal microvessels of the rat hippocampus. Microvessels in in vitro slices of the hippocampus were monitored using computer-assisted video microscopy. The effects of inhibitors of two kinases, protein kinase C and calcium/calmodulin-dependent protein kinase, on the vasoconstrictor response to NG-nitro-L-arginine (L-NNA) were investigated. The resting luminal diameter of the microvessels examined in this study ranged from 9 to 29 microns. Addition of 100 microM L-NNA to the medium superfusing the slice constricted microvessels by 38.8 +/- 0.6%. The addition of protein kinase inhibitors reversed this constriction in a dose-dependent manner. H-7 (50 microM), a relatively non-selective protein kinase C inhibitor, elicited an 81.4 +/- 10.0% reversal of the L-NNA-induced constriction. Bisindolylmaleimide (5 microM), a selective protein kinase C inhibitor, reversed the constriction by 69.1 +/- 13.7%. KN-62, an inhibitor of calcium/calmodulin-dependent protein kinase II, elicited a smaller yet statistically significant reversal of 17.1 +/- 5.1%. Pretreatment with H-7 or bisindolyl-maleimide blocked the LNNA-induced constriction entirely, while KN-62 did not significantly inhibit the response. These findings indicate that the contractile response observed upon removal of endogenous nitric oxidergic vasodilation is mediated by protein kinase activity, and the contribution of protein kinase C to this effect is greater than that of calcium/calmodulin-dependent protein kinase II. The results suggest that a tonic nitric oxidergic influence serves to mask the potential for protein kinase C-mediated vasoconstriction in cerebral microvessels.
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Affiliation(s)
- A Fergus
- Department of Neurological Surgery, University of Virginia, Charlottesville 22908, USA
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Fogarty-Mack P, Pile-Spellman J, Hacein-Bey L, Ostapkovich N, Joshi S, Vulliemoz Y, Young WL. Superselective intraarterial papaverine administration: effect on regional cerebral blood flow in patients with arteriovenous malformations. J Neurosurg 1996; 85:395-402. [PMID: 8751623 DOI: 10.3171/jns.1996.85.3.0395] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In this study the authors determined the effect of papaverine on regional cerebral blood flow (rCBF) in the angiographically normal arteriolar beds of patients with arteriovenous malformations (AVMs) who underwent transfemoral superselective angiography. Middle cerebral artery (MCA) branch vessels were catheterized during 10 procedures performed in nine patients. The mean (+/- standard deviation) largest AVM diameter was 4.4 +/- 1 cm. Regional CBF was measured by recording the washout of a bolus of xenon-133 injected through the microcatheter. In a dose-ranging study. rCBF and MCA pressure in two patients were repeatedly measured after 3-minute infusions of papaverine at 0.07, 0.7, and 7 mg/minute. In a single-dose study, an additional eight patients received only the highest dose of papaverine administered over a 3-minute period. In the dose-ranging study, CBF increased from baseline in a dose-dependent fashion. In the single-dose study, papaverine increased in rCBF 103%, from 48 +/- 11 to 95 +/- 23 ml/100 g/minute at an MCA pressure of 55 +/- 23 mm Hg. Increase in rCBF was linearly related (y = 2.2x - 17, r2 = 0.84; p = 0.001) to baseline MCA pressure (range 22-84 mm Hg). Papaverine increases rCBF in a direct proportion to baseline MCA pressure, even at low baseline pressures. Selective infusion of vasodilators should be investigated in acute cerebral hypotension to facilitate either primary or collateral recruitment of CBF by aiding spontaneous autoregulatory vasodilation. In addition, rCBF monitoring may be useful in determining the most effective intraarterial dose of papaverine while minimizing complications due to hyperemia.
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Affiliation(s)
- P Fogarty-Mack
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Clyde BL, Firlik AD, Kaufmann AM, Spearman MP, Yonas H. Paradoxical aggravation of vasospasm with papaverine infusion following aneurysmal subarachnoid hemorrhage. Case report. J Neurosurg 1996; 84:690-5. [PMID: 8613866 DOI: 10.3171/jns.1996.84.4.0690] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- B L Clyde
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania 15213, USA
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