Management of Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage: An Update

Abstract Cerebral vasospasm is one of the major complications of aneurysmal subarachnoid hemorrhage (aSAH). The term vasospasm generally refers to angiographical findings, and clinically is defined by delayed neurological deterioration and delayed cerebral ischemia. Symptomatic vasospasm occurs in 20 to 40% of aSAH patients and is one of the least understood components of management. Diagnosis can be made clinically by using bedside modalities and radiography. Management begins with the use of preventive modalities, augmentation of cerebral perfusion, attempts at reversal, and the use of brain protection. Early use of endovascular therapy with mechanical or pharmacological angioplasty remains a reasonable approach. Of proven benefit are the use of cerebral vasodilators such as nimodipine and milrinone and the use of induced hypertension for cerebral perfusion augmentation. Agents for the spasmogenic blockade, inhibition of smooth muscle contraction, and brain protection remain largely experimental. This narrative review aims to update readers on the mechanism, diagnosis, prevention, and management of vasospasm in aSAH.