What is the best time frame to utilize intra arterial verapamil for vasospasm after subarachnoid hemorrhage?

We do not use AA verapamil prophylactically. We follow our patients in the Neuro ICU with daily transcranial Doppler. If they have clinical signs or symptoms of vasospasm and TCD and CTA evidence of spasm, we take them immediately and usually perform IA injections daily until radiographically and clinically the patients improve.

I use intra-arterial verapamil as a rescue therapy for symptomatic vasospasm refractory to medical management, typically during the peak vasospasm window in the first two weeks after hemorrhage. Timing relative to symptom onset matters more than post-bleed day. I treat as early as possible once a new deficit develops or there is concern for rising TCD values or radiographic spasm on non-invasive imaging, and it fails to respond promptly to induced hypertension, since delay allows ischemia to progress to infarction. I do not use it prophylactically, as evidence does not support preventive treatment. Its effect is often transient, so I have a low threshold to repeat treatment and favor balloon or delivery-assist catheter angioplasty for focal...