210 Jimenez et al Recurrent Abrupt Occlusion after Transluminal Angioplasty for Basilar Artery Stenosis: Case Report r F IG U R E 1. Right vertebral arteriogram showing a tight eccentric stenosis at the midbasilar level (arrowhead) * and occlusion of the distal left vertebral artery just r Carlos Jimenez, M.D., Hoang Duong, M.D., Marcelo Olarte, M.D., John Pile-Spellman, M.D. Servicio de Neurocirugia (CJ), Hospital Universitario San Vincente de Paul, Medellin, Colombia, and Departments of Radiology (HD, JP-S) and Neurology (MO), Columbia University, New York, New York Key words: Angioplasty, Artheromatous stenosis, Basilar artery, Intra-arterial vasodilators asilar artery stenosis produces a stroke syndrome with variable but of­ ten poor prognosis. Currently, the only medical treatment available is the use of systemic anticoagulation. If this fails, however, the only remaining therapeutic option is percutaneous transluminal an­ gioplasty (PTA). Unfortunately, abrupt vessel occlusion commonly occurs during angioplasty, with devastating clinical con­ sequences. In this report, we were able to reverse this complication by using intraarterial papaverine. We present a litera­ ture review and a discussion of the clini­ cal and technical aspects of basilar artery angioplasty. B CASE REPORT A 58-year-old man presented with re current posterior circulation transient is chemic attacks (TIAs) of increasing se­ verity, consisting of blurred vision, diplopia, dysarthria, and perioral and facial numbness of 2 weeks' duration. Magnetic resonance (MR) imaging and MR angiography revealed a tight m id­ basilar artery stenosis and a left occipital infarct. The patient was initially m an­ aged with intravenously administered heparin (Elkins-Sinn, Inc., Cherry Hill, NJ) therapy for 1 week, resulting in no clinical improvement. Angiography was performed and did the following: 1) confirmed the presence of a tight ec­ centric stenosis at the midbasilar level (Fig. 1 ) and occlusion of the distal left vertebral artery, 2) failed to demonstrate competent posterior com municating ar­ teries supplying the basilar artery in a retrograde fashion, and 3) showed a left posterior cerebral artery occlusion. The Neurosurgery , Vol. 44, No. 1, January 1444 (arrow). patient was monitored in the neurolog- r ical intensive care unit and received va- * sopressors to maintain adequate perfu- = sion across the basilar artery stenosis : Follow-up MR im aging/M R angiogra-■ phy performed 1 week later revealed * worsening of the midbasilar stenosis and hvperintense foci on T2-weighted ^ sequences in the upper pons and the ^ right cerebellar hem isphere, which were ^ interpreted as new infarcts (Fig. 2). At that point, the decision was made to 3 offer angioplasty to prevent a major j brain stem infarct. With the patient under general anes-■ thesia, repeat angiography showed in- 3 terval progression of the basilar artery ■ stenosis above the level of the anteroin- ■ ferior cerebellar arteries (Fig. 3). Before i angioplasty, 120,000 units of urokinase(Abbott Laboratories, North Chicago n 1L), 2,000 units of heparin, and 2 mgot It verapamil (American Regent Laborato- d. ries Inc.)' were infused intra-arteriallyj in the proximal basilar arterv. Angioplasty 3 was performed with a 2 mm X 2-cm Stealth balloon microcatheter system ** (Target Therapeutics, Fremont, C A ) t h a t » was introduced via a 6-French guiding catheter positioned in the distal right e vertebral artery. The balloon was in- r flated to 6 atm ospheres, with good ini- iY tial results. Five to 10 minutes later, Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/1/210/2849565 by Nottingham Trent University user on 27 July 2019 OBJECTIVE AND IMPORTANCE: Angioplasty for basilar artery stenosis is often complicated by recurrent abrupt vessel closure. The clinical results can be catastrophic. In this case report, we assess the effects of intra-arterial papav­ erine (American Regent Laboratories Inc., Shirley, NJ) on rebound occlusion. C LIN IC A L PRESENTATION: The patient presented with crescendo transient ischemic attacks from atherosclerotic narrowing of the midhasilar artery despite maximal medical treatment. IN TERVEN TION : Angioplasty of the midbasilar artery was performed with serial balloon inflations. The patient was treated successfully with intraarterial papaverine and achieved a nearly full recovery, with only mild dysarthria, by the time of the 7-month follow-up examination. C O N C L U S IO N : Using intra-arterial papaverine, we were able to reverse the effects of this potentially life-threatening complication of basilar artery angioplasty. (N eurosurgery 4 4 : 2 1 0 - 2 1 5 , 1 9 9 9 ) below the vertebrobasilar junction w B F IG U R E 2. Preangioplasty T2* f weighted axial image showing •• hyperintense foci in the upper pons and the right cerebellum, consistent with new infarcts. Q Basilar Artery Angioplasty \ F IG U R E 3. Repeat F IG U R E 5. Final angiogram, angiogram obtained 1 week obtained after later, showing intra-arterial progression of infusion of 110 basilar artery stenosis above the level of the anteroinferior ^ cerebellar arteries. V mg of papaverine, showing significant improvement in the basilar artery lumen with good antegrade flow. examination. DISCUSSION Natural history of basilar artery occlusive disease The natural history of atherosclerotic basilar artery stenosis is reported to be highly variable (18, 25, 28, 36), with es­ timated long-term prognosis ranging from good (29) to severe neurological deficits or death (3, 8, 10, 18). One-third r "1 F IG U R E 4. Postangioplasty angiogram showing complete midbasilar artery occlusion. Arterial spasm was jA suspected. (29) to one-half (28) of patients with angiographically proven severe vertebro­ basilar artery occlusive disease progress to brain stem infarction. The reported mortality rate associated with the dis­ ease for medically managed patients ranges from 22 (4) to 86% (11). Atherosclerotic disease tends prefer­ entially to affect the proximal and mid­ dle segments of the basilar artery (4, 29) and clinically manifests as stroke syn­ drome caused by either small or large vessel disease (4). Small vessel disease has a more benign course than that of basilar artery occlusion (8). Severe basi­ lar artery stenosis or occlusion (large vessel disease) usually manifests as TIAs that announce a brain stem stroke; however, TIAs without subsequent in­ farct may also remain the sole manifes­ tation of the disease (4, 29). Although many patients respond well to anticoagulation (3, 4), some experi­ ence progressive deterioration despite m axim um therapy. Therefore, it seems appropriate to offer emergency endovascular intervention to those who ha\ e crescendo TIAs despite full anticoagula­ tion therapy, for fear of a devastating impending stroke (13). The first angioplasty experience of the basilar artery was reported in 1980 by Sundt et al. (31, 32). In 1987, Higashida et al. (12) reported the case of a brain stem infarction occurring after PTA in a patient with tandem stenosis of the basi­ lar artery. It was not until 1992 (1), si multaneously with the development of endovascular techniques (13, 14, 26, 34), that basilar artery PTA for atheroscle­ rotic disease was again reported. To date, a review of the published litera­ ture identifies a total of 35 cases (1-3, 12, 14, 15, 21, 22, 26, 27, 31-35, 38, 39), with a moderately low complication rate (20%) and no reported mortality. Com ­ Neurosurgery, Vol. 44, No. I lanuary 1999 plete clinical, cerebral blood flow, and angiographic follow-up data are avail­ able in only a minority of cases (2 of 35 cases). The mean age was 59 years (range, 48-76 yr), and the overw helm ­ ing sex preponderance was male (16 of 17 patients). The majority were treated for medically intractable TIAs (20 of 23 patients), and the postprocedure clinical condition persisted unchanged in onehalf of the patients (10 of 20 patients). At the time of follow-up, there were no new symptoms in most cases (17 of 19 cases), and restenosis in angiographic follow-up was observed in 3 of 12 pa­ tients (Table 1). Challenges of basilar artery angioplasty In 1996, both Takis et al. (33) and Nakatsuka et al. (27) pointed out the necessity of highly selective criteria for basilar artery PTA because of its poten­ tial risks. First, navigation inside the vertebrobasilar system is more difficult and hazardous than in the anterior cir­ culation because of more tortuous, smaller vessels (9,13). Second, and more importantly, the many perforating branches arising directly from the basilar artery at right angles, which supply the brain stem and the thalamus, are exposed to the dev­ astating consequences of dissection, vaso­ spasm, and ostial occlusion during bal­ loon inflation (12, 13, 26, 27, 33, 34). Therefore, the procedure is generally con­ sidered only after m edical treatm ent failure. There is a wide variety in the reported technical aspects of angioplasty for basi­ lar artery stenosis. The diameters of the balloons used ranged from 2 mm (27, 34, 38) to 3.5 mm (34), and the reported inflation pressures ranged from 1 (26) to 8 atmospheres (39). In addition, the number of inflations performed in one procedure ranged from one (5, 12, 34, 35) to six (26, 39), with durations rang­ ing from 5 seconds to 120 seconds (15) (Table 2). Intra-arterial papaverine Papaverine is a nonspecific smooth mus­ cle relaxant with a potent adenosine 3',5'cyclic monophosphate phosphodiesteraseinhibiting effect (23). Intra-arterial papaverine has been mainly reported in association Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/1/210/2849565 by Nottingham Trent University user on 27 July 2019 however, repeat angiography showed abrupt reclosure. Angioplasty was again attempted, but reocclusion occurred after 5 to 10 minutes (Fig. 4). This scenario was repeated four times with the same balloon and three times with a 2.5 mm X 2-cm Stealth balloon (Target Therapeutics). Af­ ter the eighth balloon inflation, intraarterial papaverine was administered. A total of 110 mg of papaverine was infused in small boluses into the proximal basilar artery. Control angiography revealed sig­ nificant improvement in arterial lumen, with good antegrade flow (Fig. 5). At the end of the procedure, the pa­ tient was able to follow com m ands and move all four extremities. He was kept intubated overnight in the neurological intensive care unit and was given intra­ venously administered heparin. Mild induced hypertension was also m ain­ tained. The patient was neurologically intact and reported that his TlA s had completely resolved. He was discharged home and suffered only mild dysarthria at the time of the 7-month follow-up 211 212 Jimenez et al. TABLE 1. Clinical Aspects of Basilar Artery Angioplasty in Published Literature'7 Series (Ref. No.) Sundt et al., 1980 (31) Sundt et al., 1982 (32) Higashida et al., 1987 Postoperative CBF Procedure Angiographic Follow-up Stenosis (%) (pre/post) C linical Outcome Refractory 95/20 Improved None Not done Not done 2/None 48/M Refractory 95/60 Unchanged None Not done Patent at 2 mo 5/None 3 NA NA NA Worsened Basilar thrombosis NA NA NA 4 NA NA NA Worsened Basilar thrombosis NA NA NA 5 76/M Refractory 80/NA Worsened Basilar infarction Not done Not done Several wk/ Case No. Age (yr)/Sex Indication^ 1 56/M 2 Com plication Symptoms None (12) Ahuja et al., 1992 (1) Clinical Followup (mo)/ 6 68/M Progressive 95/NA Unchanged None Not done Restenosis at 6 mo 24/None Severe/NA Improved None Not done NA 1/None 90/mild, Unchanged Brain stem infarction Not done 50% Restenosis at 6/None stroke Yamamura et al., 1994 7 54/F stroke (39) Terada et al., 1994 (35) Progressive 8 61/M Progressive stroke Houdart et al., 1995 9 67/M Refractory 1 mo residual Tight/90 Improved PICA dissection/ Not done Patent at 6 mo 12/None subclinical (14) 10 50/M Refractory Severe/NA Unchanged None Not done Patent at 6 mo 6/None 11 NA Refractory 72/46 NA None Not done Patent at 6 mo NA 12 NA Refractory 65/0 NA None Not done Patent at 6 mo NA 13 NA Refractory 74/43 NA None Not done Patent at 6 mo 20/NA 14 NA Refractory 81/95 NA None Not done Not done 9/NA 15 NA Refractory 82/59 NA None Not done Not done 51/TIAs 16 59/M Refractory 90/50 Unchanged None Not done Not done 18/None 17 52/M Refractory 70/60 Unchanged None Not done Patent at 6 wk 48/None 18 50/M Refractory 90/40 Unchanged None Not done Not done 13/None 19 60/M Refractory 90/50 Unchanged None Not done Restenosis at 6 mo 13/TIAs 20 61/M Refractory 90/50 Improved None Not done Patent at 1 mo 17/None 21 72/M Refractory 90/50 Unchanged None SPECT NA 10/None 22 56/M Refractory 90/60 Unchanged None SPECT Patent at 6 mo 13/None Takis et al., 1996 (33) 23 NA NA NA Worsened Stroke NA NA NA McKenzie et al., 1996 24 NA Refractory NA NA NA Not done NA NA 25 NA NA NA NA Stroke Not done NA NA 26 NA NA >70/NA NA NA Not done NA NA 27 NA NA >70/NA NA NA Not done NA NA 28 NA NA >70/NA NA NA Not done NA NA 29 NA NA >70/NA NA NA Not done NA NA 30 NA NA >70/NA NA NA Not done NA NA 31 NA NA >70/NA NA NA Not done NA NA 32 NA NA NA NA NA Not done NA NA 33 NA NA NA NA NA Not done NA NA 34 NA NA NA NA NA Not done NA NA 35 60/M Refractory 100/NA Improved None TC D Not done 1/None 36 58/M Refractory 90/20 Improved None TCD/SPECT Not done 2/None Nakano et al., 1995 (26) Clark et al., 1995 (5) Nakatsuka et al., 1996 (27) (22) Berger and Callahan, 1997(2) Hyodo et al., 1997 (15) Marks et al., 1997 (21) W allace et al., 1997 (38) Present case ’ pre/post, before and after surgery; CBF, cerebral blood flow; NA, information not available; PICA, posteroinferior cerebellar artery; SPECT, single photon emission computed tomography; TCD , transcranial Doppler ultrasonography; TIA, transient ischemic attack. b "Refractory" indicates refractory to maximum medical therapy, including anticoagulation, fluid therapy, and vasopressors. with cerebral vasospasm after subarach­ noid hemorrhage (6, 7, 17, 20, 24, 37, 40). Concerning atherosclerotic disease, al­ though papaverine has been used dur­ ing coronary angioplasty (16), it is not commonly used for coronary circulation (19) or in body interventional proce­ dures (30) concomitantly with angio­ plasty. In the coronary vessels, with abrupt occlusion after angioplasty, suc­ cessful treatment with papaverine was thought to be caused by its effect on resistance vessels (16). In coronary and visceral angioplasty, abrupt vessel clo­ Neurosurgery, Vol. 44, No. 1, January 1999 sure after angioplasty can occur despite vigorous anticoagulation with heparin, aspirin, and urokinase. The causes of this abrupt vessel occlusion have been thought to be thrombosis, vascular dis­ section, and elastic recoil. The a d v e n t of stents and Abciximab (Reopro, Malvern, Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/1/210/2849565 by Nottingham Trent University user on 27 July 2019 Terada et al., 1996 (34) Basilar Artery Angioplasty 213 TABLE 2. Technical Aspects of Basilar Artery Angioplasty in Published Literature Series (Ref. No.) Sundt et al., 1980 (31) Sundt et al., 1982 (32) Higashida et al., 1987 Angioplasty Device/Balloon Diameter (mm) Case No. Number of Inflations Duration of Inflation (s) Inflation Pressure (atm) Use of Medications 1 2 3 4 5 Balloon catheter/3 Balloon catheter/3 NA NA Balloon catheter/3 3 3 NA NA 1 20 20 NA NA 10 4 6 NA NA NA None None NA NA None 6 7 Stealth/2.5 Balloon catheter/3 Several 6 5-10 NA 5.44 4-8 IV heparin IV heparin 8 9 Stealth/2.5 Stealth/NA 1 NA 60 NA 4 NA IV heparin None 10 Stealth/2.5 6 30 1-3 None 11 12 13 14 15 16 Stealth/NA Stealth/NA Stealth/NA Stealth/NA Stealth/NA O ver the w ire microballoon system/2-3.5 O ver the w ire microballoon system/2-3.5 O ver the w ire microballoon system/2-3.5 O ver the w ire microballoon system/2-3.5 O ver the wire microballoon system/2-3.5 Stealth/2 1 or 2 1 or 2 1 or 2 1 or 2 1 or 2 1 10 10 10 10 10 10-20 7 7 7 7 7 6 None None None IV heparin IV heparin IV heparin 1 10-20 6 IV heparin 1 10-20 6 IV heparin 1 10-20 6 None 1 10-20 6 None 2 20 2 NA Stealth/2 iNA i #\ Balloon catheter/3 2 NA 2 20 NA 15 3 NA NA IV heparin NA NA NA NA NA NA NA 26 27 28 29 30 31 32 33 34 35 Stealth/NA Stealth/NA Stealth/NA Stealth/NA Stealth/NA Stealth/NA NA NA NA O ver the w ire microballoon NA NA NA NA NA NA NA NA NA 4 20-120 20-120 20-120 20-120 20-120 20-120 NA NA NA NA 2-6 2-6 2-6 2-6 2 -6 2-6 NA NA NA 6 36 system/2-3 Stealth/2.5 10 ,3 N A 5 IV heparin IV heparin IV heparin IV heparin IV heparin IV heparin NA NA NA IA urokinase/IA Abcixim ab IA heparin/IA urokinase/IA papaverine (12) Ahuja et al., 1992 (1) Yamamura et al., 1994 (39) Terada et al., 1994 (35) Houdart et al., 1995 (14) Nakano et al., 1995 (26) Clark et al., 1995 (5) 17 18 19 20 Nakatsuka et al., 1996 (27) Takis et al., 1996 (33) McKenzie et al., 1996 (22 ) Berger and Callahan, 1997 (2) Hyodo et al., 1997 (15) Marks et al., 1997 (21) Wallace et al., 1997 (38) Present case 21 22 23—/ 24 25 I\ / * ' ln*ravenously administered; IA, intra-arterial. Neurosurgery, Vol. 44 , No. 1, lanuary 1999 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/1/210/2849565 by Nottingham Trent University user on 27 July 2019 Terada et al., 1996 (34) 214 Jimenez et al PA) have significantly helped in dealing with these conditions. Interestingly, in a similar case with recurrent abrupt throm­ bosis of the basilar artery after thrombol­ ysis and angioplasty, which was treated with Abciximab (38), the post-Abciximab angiogram showed a patent vessel with 25 to 30% residual stenosis. Our case showed increased luminal diameter (90%), but there was still a suggestion of intralum inal defects. To our knowledge, this is the first re­ port of the intra-arterial use of papaver­ ine to reverse basilar artery abrupt oc­ clusion after PTA for atherosclerotic stenosis. Although transient, the vasodilatory effect was successful in our patient in reversing life-threatening, abrupt basi­ lar artery occlusion that that was consid­ ered to have occurred secondary to endo­ vascular manipulation. 2. Berger BL, C allahan AS III: Balloon angioplasty 18. Kubik CS, A d am s RD: O cclu sion of the basilar I for stroke prevention: Results in 73 cases. Inter­ artery: A clinical and pathological study. Brain j vent Neuroradiol 3[Suppl 1 ]:37—38, 1997. 3. C aplan LR: V ertebrobasilar disease: T im e for a new strategy. Stroke 12:111-114, 1981. occlusive disease, in Barnett H JM , M o h r JP, Stein BM, Yatsu FM (eds): Stroke: Pathophysiol­ pp 1 3 6 6 - 1 3 7 6 . ogy, Diagnosis and Management. N ew York, Churchill Livingstone, 1992, pp 4 4 3 -5 1 5 . 5. Clark W M , Barnwell SL, N esbit G, O 'N eill OR, for vasosp asm induced by subarachnoid hem- * W ynn ML, Coull BM: Safety and efficacy of orrhage. 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Terada T, Yokote H, Tsuura M, Kinoshita Y, Hayashi Y, Itakura T, Komai N: T issue p lasm in ­ ogen activator thrombolysis and translum inal angioplasty in the treatment of basilar artery thrombosis: Case report. Su rg N eurol 4 1 : 3 5 8 - 361,1994. 36. Ueda K, Toole JF, M cH enry LC: C arotid and vertebrobasilar transient ischemic attacks: C lin ­ ical and angiographic correlation. N eu ro lo g y 29:1094-1101, 1979. 37. Vardiman AB, Kopitnik TA, Purdy PD, Batjer HH, Samson DS: Treatment of traumatic arterial vasospasm with intraarterial papaverine infusion. AJNR Am J Neuroradiol 16:319-321, 1995. 38. Wallace RC, Furlan AJ, M oliterno DJ, Stevens GHJ, Masaryk TJ, Perl J II: Basilar artery re­ thrombosis: Successful treatm ent with platelet glycoprotein IIB/IIIA receptor inhibitor. A JN R Am J Neuroradiol 18:1257-1260, 1997. T, Hashi K: Percutaneous transluminal angio­ plasty for progressing stroke caused by severe basilar artery stenosis: Case report [in Japanese]. No Shinkei Geka 22:265-268, 1994. 40. Yoshimura S, T su kah ara T, H a s h im o to N, Kazekawa K, Kobayashi A: Intraarterial infu­ sion of papaverine com bined with intravenous administration of high-dose of nicard ipine for cerebral vasospasm. Acta N e u ro ch ir (W ien ) Giuseppe Lanzino L. Nelson Hopkins Buffalo , New York 135:186-190, 1995. COMMENTS The authors report a patient with cre­ scendo posterior circulation transient is­ chemic attacks secondary to a basilar artery stenosis. Percutaneous translum i­ nal angioplasty of the stenotic lesion was performed. However, the proce­ dure was complicated by recurrent, abrupt basilar artery occlusion that re­ solved after the injection of intra-arterial papaverine. This article discusses a well-known phenomenon that sometimes occurs af­ Jimenez et al. describe a 58-year-old man who presented with medically in­ tractable posterior circulation transient ischemic attacks secondary to a mid­ basilar stenosis. After undergoing an­ gioplasty, the patient experienced an abrupt occlusion, which kept recurrent and was theoretically reversed by the papaverine. There is no question that during angioplasty, this is a noxious event to the vessels, and mechanical spasm caused by angioplasty may be responsible for an abrupt occlusion. It is difficult to draw a firm conclusion that the papaverine was responsible for the reperfusion noted after papaverine deliv­ ery. The problem associated with intracra­ nial angioplasty is the abrupt occlusion that often occurs with the delivery of a controlled dissection during the perfor­ mance of angioplasty. Everyone working in this field is anxiously awaiting the ad­ vent of stent technology that will prevent this dreaded com plication. W e have much to learn from our colleagues who have written the peripheral and cardiac literature, and it will be interesting to learn whether the use of Abciximab, a platelet antiaggregant, will reduce this problem. Based on one case, it is diffi­ cult to know whether papaverine may play a role in intracranial angioplasty; however, when faced with such a diffi­ cult problem such as an acute occlusion, the experience of these authors may be useful, considering the alternative. Robert H. Rosenwasser Philadelphia , Pennsylvania This article clearly shows a beneficial effect of papaverine in a case of angio­ plasty of the basilar artery. This proce­ dure is a high-risk one but, in carefully selected cases such as this one, can be lifesaving. Interestingly, I have seldom, if ever, observed spasm after angio­ plasty but have observed dissections or raised intimal flaps. As an alternate ex­ planation, this patient may have had a dissection that repaired itself or a clot that dissipated during the course of the papaverine infusion, but I agree that it seems most likely that the result was an effect of the drug. Stanley L. Barnwell Portland , Oregon CNS Placement Service Are you looking for a job position or a new associate for your practice? The Congress of Neurological Surgeons Placement Service provides a free confidential service to its members to aid in selecting a position or a partner. Both academic and private practice opportunities are available. For further information please contact: Cameron G. McDougall, M O , Chairman C N S ^ c e m e n t C om m Ttee 2910 North 3rd Avenue, Phoem *, AZ 85013. Tel: 602/406-3957; Fax: 602/264-2417 Neurosurgery, Vol. 44, No. I, jsnuary 1999 Downloaded from https://academic.oup.com/neurosurgery/article-abstract/44/1/210/2849565 by Nottingham Trent University user on 27 July 2019 39. Yamamura A, Takamura Y, Yamaki T, Nakagawa ter transluminal angioplasty of intracra­ nial vessels, i.e., abrupt vessel closure after a successful angioplasty. Although the occlusion is often related either to platelet aggregation and thrombosis at the site of the atherosclerotic lesion or to angioplasty-induced dissection, vaso­ spasm (probably secondary to the in­ traluminal manipulation) may play a critical role and must be considered in similar situations. In such cases, as is clearly shown in the present article, lo­ cal papaverine infusion represents a rel­ atively safe and easy intervention that may result in resolution of the spasm, thereby ensuring maintenance of ade­ quate flow and permanent vessel patency. In an attempt to prevent spasm, the au­ thors had administered intra-arterial ve­ rapamil before performing angioplasty. It is worth mentioning that in similar cases, prophylactic, systemic nitroglycerin ad­ ministration may be considered as well. This concise case report adds significantly to the literature on angioplasty for intra­ cranial lesions and has significant clinical relevance because superimposed vaso­ spasm in the setting of acute vessel clo­ sure after angioplasty is often underrated. 215