Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Burns Trauma and Critical Care Research Centre, the University of Queensland, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, 4029, Brisbane, Australia.
Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia; Queensland University of Technology (QUT), Brisbane, Australia.
J Clin Neurosci. 2024 May;123:91-99. doi: 10.1016/j.jocn.2024.03.016. Epub 2024 Apr 1.
The prophylactic use of nimodipine following subarachnoid hemorrhage is a practice established four decades ago when clinical management differed from current and the concept of Delayed Cerebral Ischemia (DCI) was not established. The applicability of the original studies is limited by the fact of not reflecting current practice; by utilising a dichotomised outcome measure such as good neurological outcome versus death and vegetative state; by applying variable dosing regimens and including all causes of poor neurological outcome different than DCI. This study aims to review the available evidence to discuss the ongoing role of nimodipine in contemporaneous clinical practice.
PRISMA guidelines based review, evaluated the evidence on the prophylactic use of nimodipine. The following search engines: Medline, Embase, Cochrane, Web of Science and PubMed, identified Randomized Control Trials (RCTs) with neurological benefit as outcome measure and the impact of fixed versus weight-based nimodipine dosing regimens.
Eight RCT were selected. Three of those trials with a total of 349 patients, showed a reduction on death and vegetative state (pooled RR: 0.62; 95 % confidence interval-CI: 0.45, 0.86) related to DCI. Amongst all studies, all cause death (pooled RR = 0.73, [95 % CI: 0.56, 0.97]) favoured a fixed-dose regimen (pooled RR: 0.60; [95 % CI: 0.43, 0.85]).
Available evidence demonstrates that nimodipine only reduces the risk for DCI-related death or vegetative state and that fixed-dose regimens favour all cause infarct and death independent of DCI. Contemporaneous studies assessing the benefit of nimodipine beyond death or vegetative states and applying individualized dosing are warranted.
蛛网膜下腔出血后预防性使用尼莫地平的做法是四十年前确立的，当时的临床管理与现在不同，而且还没有确立迟发性脑缺血（DCI）的概念。原始研究的适用性受到以下事实的限制：不能反映当前的实践情况；使用二分法结果测量，如良好的神经功能预后与死亡和植物状态；应用不同的剂量方案，并将所有导致神经功能预后不良的原因都纳入，而不仅仅是 DCI。本研究旨在回顾现有证据，讨论尼莫地平在当前临床实践中的持续作用。
基于 PRISMA 指南的综述，评估了预防性使用尼莫地平的证据。使用以下搜索引擎：Medline、Embase、Cochrane、Web of Science 和 PubMed，确定了以神经功能获益为结果测量指标的随机对照试验（RCT），以及固定剂量与体重剂量尼莫地平给药方案的影响。
选择了 8 项 RCT。其中 3 项试验共 349 例患者，显示尼莫地平降低了与 DCI 相关的死亡率和植物状态（合并 RR：0.62；95%置信区间 [95%CI]：0.45，0.86）。在所有研究中，全因死亡（合并 RR=0.73，[95%CI：0.56，0.97]）倾向于固定剂量方案（合并 RR：0.60；[95%CI：0.43，0.85]）。
现有证据表明，尼莫地平仅降低了 DCI 相关死亡或植物状态的风险，而固定剂量方案独立于 DCI 有利于全因梗死和死亡。有必要进行评估尼莫地平在死亡或植物状态之外获益并应用个体化剂量的当代研究。
