Continuous Intra-arterial Infusion of Verapamil for Severe Vasospasm Treatment After Subarachnoid Hemorrhage: A Case Report

Delayed cerebral ischemia can occur after subarachnoid hemorrhage (SAH) and is associated with the development of symptomatic vasospasm. Despite medical treatments for vasospasm, it can be refractory. Endovascular approaches, including bolus injection or continuous infusion of verapamil via in situ placement of a microcatheter, can serve as rescue therapy. A 39-year-old male patient with a history of HIV-1 infection was brought to the Emergency Department (ED) after being found unconscious at home. He presented with a Glasgow Coma Scale score of 9 (E2V1M6), left hemiparesis, and isocoric, photoreactive pupils. A brain computed tomography (CT) revealed a large right frontotemporal intra-axial hemorrhage with ventricular system extravasation, right cisural SAH, and apparent aneurysmal dilation at the bifurcation of the right middle cerebral artery (MCA) classified as Modified Fisher (mFisher) scale score of 4, Hunt and Hess scale score of 4, and World Federation of Neurosurgical Societies (WFNS) grade IV. The patient underwent surgical intervention involving clipping of the ruptured aneurysm at the right MCA bifurcation and drainage of the right frontotemporal cisural hematoma. Treatment was initiated with nimodipine (30mg 6/6h) and milrinone infusion (1 mcg/kg/min). The initial transcranial color-coded Doppler (TCCD) indicated moderate-to-severe vasospasm in the right MCA (mean velocity [Vm] of right M1: 310 cm/s; Lindegaard Index [LI]: 5.1). On the fourth day of hospitalization (day 7 post-SAH), due to persistent moderate-to-severe vasospasm, the patient underwent therapeutic angiography with the placement of a microcatheter into an internal carotid artery (ICA) and continuous infusion of verapamil. Serial TCCD showed significant improvement in vasospasm (Vm of right M1: 176 cm/s; LI: 3.9). Despite optimized perfusion using individualized optimal cerebral perfusion pressure, the patient developed refractory intracranial hypertension, requiring the placement of an external ventricular drain and subsequent decompressive craniectomy. Endovascular bolus administration of verapamil produces transient and insufficient benefits in preventing secondary injury post-SAH. Continuous verapamil infusion may serve as an earlier and more durable alternative. This case illustrates the use of this technique, which is still not widely adopted, in a patient with severe vasospasm despite treatment with nimodipine and milrinone. Additionally, the use of TCCD as a non-invasive diagnostic and monitoring tool for vasospasm progression is emphasized.