Q: Why, despite no convincing angiographic evidence of nimodipine's effect on Subarachnoid Hemorrhage (SAH), does it continue to be the standard of care in SAH?
Answer: Although it is true that so far Nimodipine failed to show any concrete evidence of objective improvement of either angiographic or symptomatic vasospasm in SAH, it is considered essential, and not using it, a malpractice, in SAH management. This is because nimodipine likely dilates small arteries that are not visible on angiograms.
Other beneficial effects of nimodipine are due to the combination of:
- reduction of calcium-dependent excitotoxicity
- diminished platelet aggregation
- inhibition of ischemia triggered by red blood cell products
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References:
1. Barker FG 2nd, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis. J Neurosurg 1996; 84:405.
2. Dayyani M, Sadeghirad B, Grotta JC, et al. Prophylactic Therapies for Morbidity and Mortality After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis of Randomized Trials. Stroke 2022; 53:1993.
3. Bellapart J, Laupland KB, Malacova E, Roberts JA, Paratz J. Nimodipine prophylaxis in aneurysmal subarachnoid hemorrhage, a question of tradition or evidence: A scoping review. J Clin Neurosci. 2024 May;123:91-99. doi: 10.1016/j.jocn.2024.03.016. Epub 2024 Apr 1. PMID: 38564967.
4. Hao G, Chu G, Pan P, Han Y, Ai Y, Shi Z, Liang G. Clinical effectiveness of nimodipine for the prevention of poor outcome after aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Front Neurol. 2022 Sep 21;13:982498. doi: 10.3389/fneur.2022.982498. PMID: 36212656; PMCID: PMC9533126.
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