Tyree H Kiser1. 1. Department of Clinical Pharmacy, University of Colorado School of Pharmacy and Pharmaceutical Sciences, and Critical Care Pharmacy Specialist, University of Colorado Hospital.
Abstract
Background: Cerebral vasospasm and delayed cerebral ischemia continue to be major contributors to morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Purpose: The purpose of this review was to evaluate the pharmacotherapy interventions for the prevention and management of cerebral vasospasm in patients with SAH. Methods: A search of MEDLINE (January 1966-April 2012) and EMBASE (January 1974-April 2012) was conducted to retrieve relevant studies of pharmacotherapy options for prevention or treatment of cerebral vasospasm in SAH. Results: Triple-H therapy (hypervolemia, hemodilution, hypertension) has been a widely accepted option by many clinicians for the management of cerebral vasospasm and delayed cerebral ischemia. However, implementation of Triple-H therapy varies considerably at individual institutions. Nimodipine and nicardipine have demonstrated the most dependable improvements in patient outcomes to date. High doses of intravenous magnesium have failed to show consistent benefits. Magnesium supplementation to prevent hypomagnesaemia should be employed. Statin therapy should be continued in patients who are taking statins prior to hospital admission. Use of statins in naive patients may be recommended when the results of an ongoing prospective study are available. Of the available locally administered pharmacologic therapies, nicardipine and thrombolytics appear to provide the most intriguing benefit-to-risk ratio. However, the data supporting the use of locally administered therapy are modest at best and require careful consideration prior to application. Conclusions: Clinical studies have tested a variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm. Of available therapies, nimodipine has demonstrated consistent benefits and should be employed routinely. Demonstration of reduced cerebral vasospasm and improved neurological outcomes in larger prospective studies are needed for most pharmacologic therapy options prior to recommending their routine use.
Background: Cerebral vasospasm and delayed cerebral ischemia continue to be major contributors to morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Purpose: The purpose of this review was to evaluate the pharmacotherapy interventions for the prevention and management of cerebral vasospasm in patients with SAH. Methods: A search of MEDLINE (January 1966-April 2012) and EMBASE (January 1974-April 2012) was conducted to retrieve relevant studies of pharmacotherapy options for prevention or treatment of cerebral vasospasm in SAH. Results: Triple-H therapy (hypervolemia, hemodilution, hypertension) has been a widely accepted option by many clinicians for the management of cerebral vasospasm and delayed cerebral ischemia. However, implementation of Triple-H therapy varies considerably at individual institutions. Nimodipine and nicardipine have demonstrated the most dependable improvements in patient outcomes to date. High doses of intravenous magnesium have failed to show consistent benefits. Magnesium supplementation to prevent hypomagnesaemia should be employed. Statin therapy should be continued in patients who are taking statins prior to hospital admission. Use of statins in naive patients may be recommended when the results of an ongoing prospective study are available. Of the available locally administered pharmacologic therapies, nicardipine and thrombolytics appear to provide the most intriguing benefit-to-risk ratio. However, the data supporting the use of locally administered therapy are modest at best and require careful consideration prior to application. Conclusions: Clinical studies have tested a variety of pharmacotherapy interventions for the prevention and treatment of cerebral vasospasm. Of available therapies, nimodipine has demonstrated consistent benefits and should be employed routinely. Demonstration of reduced cerebral vasospasm and improved neurological outcomes in larger prospective studies are needed for most pharmacologic therapy options prior to recommending their routine use.
Authors: Michael N Diringer; Thomas P Bleck; J Claude Hemphill; David Menon; Lori Shutter; Paul Vespa; Nicolas Bruder; E Sander Connolly; Giuseppe Citerio; Daryl Gress; Daniel Hänggi; Brian L Hoh; Giuseppe Lanzino; Peter Le Roux; Alejandro Rabinstein; Erich Schmutzhard; Nino Stocchetti; Jose I Suarez; Miriam Treggiari; Ming-Yuan Tseng; Mervyn D I Vergouwen; Stefan Wolf; Gregory Zipfel Journal: Neurocrit Care Date: 2011-09 Impact factor: 3.210
Authors: Andrew M Naidech; Ali Shaibani; Rajeev K Garg; Isis M Duran; Storm M Liebling; Sarice L Bassin; Bernard R Bendok; Richard A Bernstein; H Hunt Batjer; Mark J Alberts Journal: Neurocrit Care Date: 2010-12 Impact factor: 3.210
Authors: John Myburgh; D James Cooper; Simon Finfer; Rinaldo Bellomo; Robyn Norton; Nicole Bishop; Sing Kai Lo; Shirley Vallance Journal: N Engl J Med Date: 2007-08-30 Impact factor: 91.245
Authors: Mervyn D I Vergouwen; Joost C M Meijers; Ronald B Geskus; Bert A Coert; Janneke Horn; Erik S G Stroes; Tom van der Poll; Marinus Vermeulen; Yvo B W E M Roos Journal: J Cereb Blood Flow Metab Date: 2009-05-20 Impact factor: 6.200
Authors: As'ad Ehtisham; Scott Taylor; Linda Bayless; Owen B Samuels; Michael W Klein; Jeff M Janzen Journal: South Med J Date: 2009-02 Impact factor: 0.954