• 
• 

Three Part Question

[In patients with proven subarachnoid haemorrhage] is[Nimodipine better than placebo] at [in mortality and neurological sequelae]?

Clinical Scenario

A 24 year old man presents to the emergency department following a sudden headache and collapse. He presents with a GCS of 13 and a weakness of the left side. Computed tomography confirms a subarachnoid bleed. You refer him to the neurosurgeons who suggest putting him on nimodipine to reduce cerebral vasospasm. You are too embarrassed to ask why.

Search Strategy

Medline 1966-01/04 using the Ovid interface.
[subarachnoid.mp OR exp.subarachnoid hemorrhage] AND [Nimodipine.mp OR exp Nimodipine] LIMIT to human, English AND abstracts.

Search Outcome

Altogether 465 papers found. One recent Cochrane systematic review identified. No relevant papers published after the date of the systematic review. The review was critically appraised.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Cochrane Stroke Group, 2002, Netherlands	Papers selected from the Cochrane Stroke Group Trials Register (last searched November 2001), handsearch of two Russian journals (1990-1995), contacted trialists and pharmaceutical companies to identify further studies	Systematic review and meta-analysis	Number of relevant papers (Ca antagonists and SAH)	11 papers with 2804 randomised patients	This is a well performed review article. Much of the data is pooled across 4 different types of Ca antagonsits. However, the authors also show that the greatest benefit appears to be when nimpodipine is used (as opposed to the other Ca antagonists) and when it is given orally rather than IV.
			Number of papers specific to nimodipine	8 trials with 1574 randomised patients
			Effect on poor outcome Ca antagonist vs. placebo	RR of 0.82 (0.72-0.93) in favour of Ca antagonists
			Effect on fatality	RR of 0.89 (0.75- 1.06) in favour of Ca antagonists
			Clinical signs of secondary ischaemic neurological deficit	RR of 0.67 (0.59-0.76) in favour of Ca antagonists
			CT evidence of secondary ischaemia	RR of 0.80 (0.71-0.89) in favour of Ca antagonists
			Rebleeding after SAH	RR of 0.77 (0.58-1.02) in favour of Ca antagonists

Comment(s)

SAH is a devastating illness. Treatment with calcium antagonsits appears to offer a decrease in secondary ischaemic events in these patients. This is shown by the reduction in mortality and clinical findings. Although not specifically addressed in the BET, oral nimodipine appears to be the first choice of drug.

Clinical Bottom Line

Oral nimodipine is an important adjuvant treatment for subarachnoid haemorrhage.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Rinkel GJE, Feigin VL, Algra A, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Library Issue 4. Oxford: Update Software, 2002.