Morphological changes of intracranial pressure quantifies vasodilatory effect of verapamil to treat cerebral vasospasm

Abstract

IntroductionAfter aneurysmal subarachnoid hemorrhage (SAH), both proximal and distal cerebral vasospasm can contribute to the development of delayed cerebral ischemia. Intra-arterial (IA) vasodilators are a mainstay of treatment for distal arterial vasospasm, but no methods of assessing the efficacy of interventions in real time have been established.ObjectiveTo introduce a new method for continuous intraprocedural assessment of endovascular treatment for cerebral vasospasm.MethodsThe premise of our approach was that distal cerebral arterial changes induce a consistent pattern in the morphological changes of intracranial pressure (ICP) pulse. This premise was demonstrated using a published algorithm in previous papers. In this study, we applied the algorithm to calculate the likelihood of cerebral vasodilation (VDI) and cerebral vasoconstriction (VCI) from intraprocedural ICP signals that are synchronized with injection of the IA vasodilator, verapamil. Cerebral blood flow velocities (CBFVs) on bilateral cerebral arteries were studied before and after IA therapy.Results192 recordings of patients with SAH were reviewed, and 27 recordings had high-quality ICP waveforms. The VCI was significantly lower after the first verapamil injection (0.47±0.017) than VCI at baseline (0.49±0.020, p<0.001). A larger dose of injected verapamil resulted in a larger and longer VDI increase. CBFV of the middle cerebral artery increases across the days before the injection of verapamil and decreases after IA therapy.ConclusionThis study provides preliminary validation of an algorithm for continuous assessment of distal cerebral arterial changes in response to IA vasodilator infusion in patients with vasospasm and aneurysmal SAH.

Primary results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following Aneurysm Subarachnoid Hemorrhage (VITAL) Study

“…The use of IA vasodilators is a relatively safe treatment, with immediate improvement in cerebral perfusion. Recent studies have demonstrated the immediate impact on cerebral perfusion after infusion of verapamil with a dose-dependent response 14. Unfortunately, the effect of these medications is temporary and in many cases they fail to achieve adequate vessel dilation, with frequent recurrence of CV requiring multiple treatments 15 16.…”

The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management

“…This situation is probably the most difficult to defining therapeutics. Although initial medical management of IH and cerebral tissue hypoxia is based on individual institutional guidelines or international consensus [ 4 , 66 , 67 ], it is essential to keep in mind the following premises: (a) close, continued follow-up monitoring and further therapeutic response based on wave morphology [ 68 , 69 ]; (b) refrain from escalation of any medical treatment beyond recommended levels, if the response to that intervention is not satisfactory; and (c) early consideration of CSF drainage and/or surgical evacuation of space-occupying injuries or decompression of the cranial cavity.…”

RAQ: a novel surrogate for the craniospinal pressure–volume relationship

“…Associations with other parameters and diagnoses were described as well (Hamilton et al 2016, Kasprowicz et al 2012. The method was also used to characterize cerebral vascular changes during acute ICP drop in subarachnoid hemorrhage (Liu et al 2019, Liu et al 2020. However, it has not found widespread entry into clinical routine so far.…”