Triple-H
therapy (hypervolemia,
hemodilution,
hypertension) has been a widely accepted option by many clinicians for the management of
cerebral vasospasm and delayed
cerebral ischemia. However, implementation of Triple-H
therapy varies considerably at individual institutions.
Nimodipine and
nicardipine have demonstrated the most dependable improvements in patient outcomes to date. High doses of intravenous
magnesium have failed to show consistent benefits.
Magnesium supplementation to prevent hypomagnesaemia should be employed.
Statin therapy should be continued in patients who are taking
statins prior to hospital admission. Use of
statins in naive patients may be recommended when the results of an ongoing prospective study are available. Of the available locally administered pharmacologic
therapies,
nicardipine and thrombolytics appear to provide the most intriguing benefit-to-risk ratio. However, the data supporting the use of locally administered
therapy are modest at best and require careful consideration prior to application.
Conclusions: Clinical studies have tested a variety of
pharmacotherapy interventions for the prevention and treatment of
cerebral vasospasm. Of available
therapies,
nimodipine has demonstrated consistent benefits and should be employed routinely. Demonstration of reduced
cerebral vasospasm and improved neurological outcomes in larger prospective studies are needed for most pharmacologic
therapy options prior to recommending their routine use.