Critically evaluate the current approaches to the treatment of cerebral vasospasm following aneurysmal subarachnoid haemorrhage.
b) Triple H therapy-HT, hypervolemia and hemodilution-controversial, not evidence based
c) Early clipping / coiling
d) Nimodipine -useful in prophylaxis,
e) Endoluminal·therapies: Balloon angioplasty and intra-arterial papaverine
Investigational therapies -proven in animal models, no hard clinical evidence, no RCT
1) Statins-Early human data
2) Cisternal tPa
3) Endothelin antagonists
This topic is well developed in the chapter on subarachnoid haemorrhage.
True to the college answer, there is only strong evidence for nimodipine and endovascular vasodilators. Of the "triple-H" therapy, the only evidence-based component is probably hypertension, and even this is being debated.
Judging by the college answer, they did not want a discussion of Class I recommendations from highly regarded advisory bodies. The model answer mentions some wacky "failed therapies" for vasospasm which have subsequently receded into historical background noise.
Poorly supported therapies
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Myburgh, J. A. "Triple h” therapy for aneurysmal subarachnoid haemorrhage: real therapy or chasing numbers." Crit Care Resusc 7.3 (2005): 206-212.
Bederson, Joshua B., et al. "Guidelines for the management of aneurysmal subarachnoid hemorrhage a statement for healthcare professionals from a special Writing Group of the Stroke Council, American Heart Association."Stroke 40.3 (2009): 994-1025.
Kawamoto, Shunsuke, et al. "Effectiveness of the head-shaking method combined with cisternal irrigation with urokinase in preventing cerebral vasospasm after subarachnoid hemorrhage." Journal of neurosurgery 100.2 (2004): 236-243.
Vergouwen, Mervyn DI, et al. "Biologic effects of simvastatin in patients with aneurysmal subarachnoid hemorrhage: a double-blind, placebo-controlled randomized trial." Journal of Cerebral Blood Flow & Metabolism 29.8 (2009): 1444-1453.
Macdonald, R. Loch, et al. "Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) Randomized, Double-Blind, Placebo-Controlled Phase 2 Dose-Finding Trial."Stroke 39.11 (2008): 3015-3021.