Aneurysmal subarachnoid hemorrhage (SAH) accounts for a significant percentage of morbidity and mortality among patients admitted to neurosurgical centers throughout the world. Even for individuals surviving beyond the initial presentation and intervention for aneurysmal SAH, the occurrence of
cerebral vasospasm has the potential to induce a second tier of complications that can be just as devastating as the inciting event. However, despite numerous studies and some initial advancements in management, therapeutic modalities are limited to help prevent or treat this complex entity. Historically, the mainstay of treatment for
cerebral vasospasm has been a combination of hypervolemia,
hemodilution, and
hypertension. In addition, other systemic
therapies such as oral
nimodipine,
statins, and intravenous
magnesium, as well as intensive
glucose control, appear to have some promise, although they are limited at times by adverse effects. To avoid these adverse consequences and perhaps gain some modicum of efficacy, attempts have been made to use
endovascular techniques to physically dilate vessels or to administer drugs directly to the site of action and thus avoid many of the untoward effects of systemic
pharmacotherapy. Controversy still remains over the success of intraarterial
therapy, the drugs or techniques to be used, and the best timing of this
therapy. Based on the currently available literature, it is impossible to assess the most effective intraarterial
therapy. Randomized controlled trials that can control for baseline factors and technical expertise are needed to provide more conclusive data. Clinical pharmacists should be actively involved in assisting interventional radiologists and neurosurgeons in providing safe and appropriate
pharmacotherapy in this promising but controversial arena of intraarterial
drug delivery.