Verapamil use in interventional neuroradiology: A case series of postoperative pulmonary edema

Abstract

Cerebral Vasospasm is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) which results in delayed cerebral ischemia. Cerebral vasospasm in elective endovascular management of intracranial aneurysms rarely has been reported, and the vasospasm in this situation results from irritation by the endovascular catheter. The choice of intra-arterial (IA) vasodilators is variable among clinicians. Many studies describe the use of intra-arterial vasodilators in the neurosurgery and neuroradiology literature and comment that it is safe without major complications. Calcium-channel blockers are reported to be safe in regards to hemodynamics and potential complications. Nimodipine is considered the only calcium channel blocker that has neuroprotective effect and the only vasodilator that proved to improve outcome. The use of Intra-arterial verapamil has been reported in the last 2 decades, and with the frequent and safe use, the doses are reported to be higher in the recent reports with no major complications. We report the first case series where the use of high dose Intra-arterial verapamil resulted in postoperative pulmonary edema. Neurosurgeons and neuroanesthesiologists need to be aware of the potential complications from the use of verapamil as a negative inotropic agent in this patient population. Keywords: Cerebral vasospasm, Endovascular treatment of cerebral vasospasm, Intra-arterial vasodilators, Intra-arterial verapamil, Verapamil induced pulmonary edema