Thao Nguyen, DO
University of Texas Health Science Center At Houston
Houston, Texas
Disclosure information not submitted.
Varun Kannan, MD
Resident Physician
Baylor College of Medicine, United States
Disclosure information not submitted.
Viola Caretti, MD
Resident Physician
Baylor College of Medicine, United States
Disclosure information not submitted.
Jon Cokley, PharmD
Clinical Pharmacist
Baylor College of Medicine, United States
Disclosure information not submitted.
Daniel Davila-Williams, MD
Assistant Professor
Baylor College of Medicine, United States
Disclosure information not submitted.
Title: Use of Intra-arterial Verapamil in an Infant with Cerebral Vasospasm from Subarachnoid Hemorrhage
Introduction: Cerebral vasospasm can cause devastating delayed cerebral ischemia in the setting of subarachnoid hemorrhage (SAH). While there is substantial evidence guiding management of vasospasm in adult aneurysmal SAH, there is a lack of safety and efficacy data in the pediatric population. Here, we present a case of an infant with symptomatic cerebral vasospasm secondary to aneurysmal SAH who was successfully treated with intra-arterial (IA) verapamil.
Description: A healthy 5-month-old male presented with progressive lethargy after a minor fall, likely with cervical acceleration-deceleration. Initial head imaging confirmed extensive SAH of basal cisterns with intraventricular hemorrhage and hydrocephalus requiring emergent intubation and external ventricular device (EVD) placement. Vessel imaging confirmed a ruptured 6.3 cm traumatic pseudoaneurysm of the right vertebral artery. He underwent successful aneurysm coiling with arterial sacrifice. Prophylactic nimodipine was started, and he underwent continuous EEG monitoring and daily transcranial dopplers (TCDs) for vasospasm screening. On hospital day 7, he developed left hemiparesis associated with increases in Lindegaard ratios (LRs). Head imaging confirmed acute infarcts in the territory of the right anterior cerebral artery. Conventional angiography revealed severe vasospasm of bilateral internal carotid termini and left vertebral artery, so IA verapamil (2.5 to 5 mg doses) was administered with ~50% improvement of vessel caliber. Post-intervention TCDs also showed improved LRs. The patient had some persistent deficits but was able to be successfully extubated with subsequent EVD removal and transfer to a rehabilitation unit.
Discussion: Given that our patient had worsening vasospasm causing cerebral ischemia despite standard preventative measures, angiographic intervention was indicated to avoid further neurological deterioration. Improvement in vessel caliber, LRs, and motor exam post-treatment suggest that IA verapamil was successful with no adverse complications from the procedure. To our knowledge, our case is the first to demonstrate safe and efficacious use of IA verapamil in the treatment of cerebral vasospasm in an infant. Further studies for this potentially devastating condition are needed to allow prompt intervention and improved outcomes.