Pharmacologic Options for Prevention and Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Clinical Characteristics as Predictors of Early and Delayed Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage Patients: A Meta-Analysis of 4527 Cases

BACKGROUND

Predictors of delayed cerebral infarction (DCI) and early cerebral infraction (ECI) among aneurysmal subarachnoid hemorrhage (aSAH) patients remain unclear. We aimed to systematically review and synthesize the literature on predictors of ECI and DCI among aSAH patients.

METHODS

We systematically searched PubMed, EMBASE, Cochrane Library, and Scopus databases comprehensively from inception through January 2024 for observational cohort studies examining predictors of DCI or ECI following aneurysmal SAH. Studies were screened, reviewed, and meta-analyzed, adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. The data were pooled as Odds ratios (OR) with 95% confidence intervals using Review Manager 5.4 software. Methodologic quality was assessed with the Newcastle-Ottawa Scale.

RESULTS

Our meta-analysis included 12 moderate to high-quality cohort studies comprising 4527 patients. Regarding DCI predictors, Higher severity scores (OR = 1.49, 95% confidence interval [1.12, 1.97], P = 0.005) and high Fisher scores (OR = 2.23, 95% confidence interval [1.28, 3.89], P = 0.005) on presentation were significantly associated with an increased risk of DCI. Also, the female sex and the presence of vasospasm were significantly associated with an increased risk of DCI (OR = 3.04, 95% confidence interval [1.35, 6.88], P = 0.007). In contrast, preexisting hypertension (P = 0.94), aneurysm treatment (P = 0.14), and location (P = 0.16) did not reliably predict DCI risk. Regarding ECI, the pooled analysis demonstrated no significant associations between sex (P = 0.51), pre-existing hypertension (P = 0.63), severity (P = 0.51), or anterior aneurysm location versus posterior (P = 0.86) and the occurrence of ECI.

CONCLUSION

Female sex, admission disease severity, presence of vasospasm and Fisher grading can predict DCI risk post-aSAH. Significant knowledge gaps exist for ECI predictors. Further large standardized cohorts are warranted to guide prognosis and interventions.

Letter to the editor: "Beyond nimodipine: advanced neuroprotection strategies for aneurysmal subarachnoid hemorrhage vasospasm and delayed cerebral ischemia"

This letter commends the article by Luzzi et al. on alternative neuroprotection strategies for aneurysmal subarachnoid hemorrhage (SAH). It highlights the pharmacological advantages of nicardipine, cilostazol, and clazosentan over nimodipine in managing cerebral vasospasm and delayed cerebral ischemia. Emphasizing the need for personalized medicine, it advocates for integrating genetic screening and advanced monitoring techniques to tailor treatments to individual patient profiles. This approach could significantly improve clinical outcomes by optimizing drug efficacy and minimizing adverse effects.

A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage.

OBJECTIVE

To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era.

METHODS

A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage.

RESULTS

Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy.

CONCLUSIONS

Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.