Neuroprotection Calcium Channel Antagonists

Several prospective, randomized, placebo-controlled, double-blinded, randomized trials have investigated the efficacy of calcium-channel antagonists to reduce mortality and DINDs (46-49). Early studies consistently demonstrated a significant improvement in morbidity in patients treated with nimodipine (relative to placebo). Despite differences in morbidity, the placebo and nimodipine-treated groups consistently showed no difference in angiographic vasospasm, suggesting a neuroprotective effect rather than a vasodilating mechanism (46,47). Despite some studies reporting clinical efficacy, the Cooperative Aneurysm Study reported that, although patients treated with high-dose intravenous calcium antagonists had a reduction in symptomatic vasospasm, the two groups had similar outcomes at three months (48,49). Despite these negative findings, the authors conclude that calcium-channel antagonists still reduce the risk of symptomatic cerebral vasospasm in a significant proportion of patients and, therefore, still have a role in treating and preventing vasospasm. The inconsistency across studies probably arises from a lack of power to detect a small but statistically and clinically significant difference between the two treatment groups. Although some have questioned the quality of the evidence for the role of nimodipine in preventing and protecting against the sequelae of vaso-spasm, many argue that the risks (largely that of hypotension) are minimal in light of its potential benefit ( 50 ).

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