Treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis

Eur Radiol. 2017 Aug;27(8):3333-3342. doi: 10.1007/s00330-016-4702-y. Epub 2016 Dec 21.

Abstract

Objectives: To examine the clinical outcome of aneurysmal subarachnoid haemorrhage (aSAH) patients exposed to cerebral vasospasm (CVS)-targeted treatments in a meta-analysis and to evaluate the efficacy of intra-arterial (IA) approaches in patients with severe/refractory vasospasm.

Methods: Randomised controlled trials, prospective and retrospective observational studies reporting clinical outcomes of aSAH patients exposed to CVS targeted treatments, published between 2006-2016 were searched using PubMed, EMBASE and the Cochrane Library. The main endpoint was the proportion of unfavourable outcomes, defined as a modified Rankin score of 3-6 at last follow-up.

Results: Sixty-two studies, including 26 randomised controlled trials, were included (8,976 patients). At last follow-up 2,490 of the 8,976 patients had an unfavourable outcome, including death (random-effect weighted-average, 33.7%; 99% confidence interval [CI], 28.1-39.7%; Q value, 806.0; I 2 = 92.7%). The RR of unfavourable outcome was lower in patients treated with Cilostazol (RR = 0.46; 95% CI, 0.25-0.85; P = 0.001; Q value, 1.5; I 2 = 0); and in refractory CVS patients treated by IA intervention (RR = 0.68; 95% CI, 0.57-0.80; P < 0.0001; number needed to treat with IA intervention, 6.2; 95% CI, 4.3-11.2) when compared with the best available medical treatment.

Conclusions: Endovascular treatment may improve the outcome of patients with severe-refractory vasospasm. Further studies are needed to confirm this result.

Key points: • 33.7% of patients with cerebral Vasospasm following aneurysmal subarachnoid-hemorrhage have an unfavorable outcome. • Refractory vasospasm patients treated using endovascular interventions have lower relative risk of unfavourable outcome. • Subarachnoid haemorrhage patients with severe vasospasm may benefit from endovascular interventions. • The relative risk of unfavourable outcome is lower in patients treated with Cilostazol.

Keywords: Cerebral vasospasm; Delayed cerebral ischaemia; Endovascular treatment; Meta-analysis; Subarachnoid haemorrhage.

Publication types

  • Meta-Analysis
  • Review
  • Systematic Review

MeSH terms

  • Cilostazol
  • Endovascular Procedures / methods
  • Humans
  • Prognosis
  • Randomized Controlled Trials as Topic
  • Subarachnoid Hemorrhage / complications*
  • Tetrazoles / therapeutic use
  • Treatment Outcome
  • Vasodilator Agents / therapeutic use
  • Vasospasm, Intracranial / etiology*
  • Vasospasm, Intracranial / therapy*

Substances

  • Tetrazoles
  • Vasodilator Agents
  • Cilostazol