A 55-year-old female presented in 2010 with a World Federation of Neurosurgeons (WFNS) grade 3 subarachnoid haemorrhage (SAH). She had aneurysms of the right middle cerebral artery (MCA) (Fig.1A) and anterior choroidal arteries, plus a left pericallosal and anterior cerebral aneurysm (ACA). Clipping was delayed by emergent Takotsubo cardiomyopathy. Coiling of the ACA aneurysm was uneventful, however the MCA aneurysm was uncoilable. Subsequent right MCA spasm was refractory to intrarterial nimodipine, and angioplasty was contraindicated given its proximity to the aneurysm (Fig. 1B). Triple-H therapy was complicated by cardiac dysfunction. Severe hemiparesis prompted urgent surgical intervention, and undiluted papaverine (120 mg/10mL) was applied directly to the spastic MCA and all other aneurysm parent vessels after clipping. We irrigated all vessels except for the right MCA with saline prior to closure. The patient responded dramatically; her hemiparesis improved significantly and transcranial Doppler showed immediate and persistent reduction in right MCA velocity from 268 cm/s to 76 cm/s.
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