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Three Part Question

Should [patients with clinically suspected SAH] [be given nimodipine while awaiting CT Scan brain OR CT Scan has confirmed the diagnosis ] [with regard to ischaemic damage]

Clinical Scenario

A 42 yr old radio presenter presented to emergency department with sudden onset occipital headache followed by expressive dysphasia. Examination revealed GCS 12/15 (E4 V2 M6). The symptoms reported are classical of SAH and it will take at least 2-3 hrs for CT scan for diagnosis. Should nimodipine be given while awaiting CT scan to give its benefits of reducing cerebral vasospasm and secondary ischaemic damage?

Search Strategy

Medline 1966 to date
(nimodipine and SAH, treatment of SAH, nimodipine, SAH)

Search Outcome

466 papers found. One paper was a recent Cochrane systematic review which indicated the benefits of giving nimodipine after diagnosis of SAH following CT scan. No papers were found regarding giving nimodipine in clinically suspected SAH before CT scan.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses

Comment(s)

SAH is a terrible illness affecting especially in the age group of less than 60 yrs and more common in females. The poor outcome in the group of people surviving this illness is mostly due to secondary ischaemia and it is worst in group of people graded from Grade 3 to 5 of Hunt –Hess grading system and from emergency department point of view- starting the treatment as soon as possible is the only help we can give this group of patients other than diagnosing the SAH. Decreased blood pressure is the most common side effect occurring in 4.4 % of patients. And other side effects are headache, nausea and bradycardia which occurs in less than 1.0%

Clinical Bottom Line

Even though no paper is found regarding treatment with nimodipine in clinically suspected SAH before CT Scan, nimodipine benefits has been proven in reducing neurological deficit and it should be given prophylactically while awaiting CT Scan to help reduce secondary ischaemic damage. Studies into its use as prophylaxis before scans would be beneficial.

References

1. Rinkel GJE, Fergin VL, Algra A, et al. Calcium antagonist for aneurysmal subarachnoid haemorrhage. Cochrane library issue 4 2002;Oxford :Update software
2. Ged Brown, Simon Carley. Does nimodipine reduce mortality and secondary ischaemic events after subarachnoid haemorrhage. BestBETs Database[Online] accessed 02/09/05