2024 FSA Podium and Poster Abstracts
P013: USING CALCIUM CHANNEL BLOCKERS TO TREAT INTRAOPERATIVE CEREBRAL VASOSPASM
Valentina Rojas Ortiz, MD1; Oleg Desyatnikov, DO1; Harshvardhan Rajen, MD1; Katari Carello, MD2; Alejandra Figueroa, MD1; 1HCA Florida Kendall Hospital; 2Wolfson Children's Hospital
Cerebral vasospasm is commonly seen in 50-80% of pediatric patients with aneurysmal subarachnoid hemorrhage. In select patients that develop symptomatic or severe cerebral vasospasm despite medical management may require mechanical balloon angioplasty or intra-arterial administration of calcium channel blockers or other antihypertensives. We present the case of a critically ill 10 month old female who experienced cerebral vasospasm while undergoing transarterial embolization of Vein of Galen malformation.
Our patient is a 10 month old female with a past medical history of vein of Galen malformation that was diagnosed prenatally, as well as high output heart failure. She had previously undergone several cerebral angiograms with embolization since birth. She had another transvenous embolization performed the day prior, during which she developed signs of increased intracranial pressure. A stat CT scan of her brain revealed a hemorrhage into the right lateral ventricle and an external ventricular drain was placed. She eventually had bilateral drains placed along with an intracranial pressure monitor. The patient then developed status epilepticus that was medically managed with anti-epileptic medications.
The next day she developed frank hemorrhage from the ventricular drain coupled with elevated intracranial pressure and was taken emergently for transarterial embolization. The patient was transported from the ICU to the OR intubated, sedated, and paralyzed. The patient underwent general anesthesia with intravenous induction and maintenance with both volatile anesthetic and intravenous medication. Intraoperative hemoglobin was found to be 6.3 and she received 1 unit of pRBC.
During the procedure, the intracranial pressure monitor had an abrupt increase from pressure reading of 5 to 61. Discussion was had with the surgeon, who suspected cerebral vasospasm was occurring due to mechanical manipulation of the vessel during embolization. Request was made to administer intra-arterial verapamil in order to treat the vasospasm. However before medication could be given the vasospasm broke and the procedure was completed without further events and the patient was returned to the ICU. This case brings to light an important consideration for administering intra-arterial verapamil in patients who are hemodynamically unstable.
There are not many cases reported in the literature for treating hemodynamically unstable patients who then experience cerebral vasospasm. Commonly, verapamil and nitroglycerin are typically the medications of choice when treating cerebral vasospasm in older pediatric patients. However in the age range of our patient, there is not as much data regarding the possible systemic effect of these medications and what dose range is appropriate to minimize systemic blood pressure effects. Another method of treating vasospasm without medication use that has been successful is the sequential mechanical angioplasty, however this procedure does carry risk of dissection or worsening of the vasospasm.
Careful balance of these patients is key in order to safely manage their condition. There are many different ways that cerebral vasospasm can be treated, as depending on the severity of spasm there may be more urgency to the treatment options available.