Key result
Intra-arterial vasodilators for vasospasm following aSAH achieved an 89% immediate angiographic response (95% CI 83-94%) and 57% neurological improvement, but were not superior to controls.
Why the study?
Do intra-arterial vasodilators improve angiographic response, neurological response, clinical outcome, and mortality in adults with vasospasm following aneurysmal subarachnoid hemorrhage?
Meta-Analysis (n=1,571)
Do intra-arterial vasodilators improve angiographic response, neurological response, clinical outcome, and mortality in adults with vasospasm following aneurysmal subarachnoid hemorrhage?
Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage yield robust angiographic responses but are not superior to medical management or balloon angioplasty for clinical outcomes.
OBJECTIVE: The efficacy of intra-arterial vasodilators (IADs) for the treatment of vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) remains debatable. The objective of this meta-analysis was to pool estimates of angiographic and neurological response, clinical outcome, and mortality following treatment of vasospasm with IADs. METHODS: We searched PubMed, Embase, Scopus, Clinicaltrials.gov, Cochrane database, and CINAHL in December 2015 and August 2016. Studies reporting angiographic and neurological response, clinical outcome, and mortality following IAD treatment of vasospasm in 10 or more adults with aSAH were included. All established IADs were allowed. Two authors independently selected studies and abstracted the data. Mean weighted probabilities (MWP) were calculated using random effects model. RESULTS: Inclusion criteria were met by 55 studies (n=1571). MWP for immediate angiographic response to IAD treatment was 89% (95% CI 83% to 94%), post-IAD neurological improvement 57% (95% CI 49% to 65%), good outcome 66% (95% CI 60% to 71%), and mortality was 9% (95% CI 7% to 12%). After adjusting for publication bias, MWP for mortality was 5% (95% CI 4% to 7%). When transcranial Doppler (TCD) was used along with clinical deterioration for patient selection, rates of neurological response (64%) and good outcome (72%) were better. IADs were not superior to controls (balloon angioplasty or medical management). CONCLUSION: IAD treatment leads to a robust angiographic response and fair (but lower) rates of neurological response and good clinical outcome. Mortality was lower than the average reported in the literature. Rates of neurological response and good outcome were better when TCD was used for patient selection. Carefully designed studies are needed to compare IADs against medical management and balloon angioplasty.
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Venkatraman et al. (2017) conducted a meta-analysis in vasospasm following aneurysmal subarachnoid hemorrhage (n=1,571). Intra-arterial vasodilators vs. balloon angioplasty or medical management was evaluated on immediate angiographic response (95% CI 83% to 94%). Intra-arterial vasodilators for vasospasm following aSAH achieved an 89% immediate angiographic response (95% CI 83-94%) and 57% neurological improvement, but were not superior to controls.
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