AUTHOR=Chousterman Benjamin , Leclère Brice , Morisson Louis , Eude Yannick , Gayat Etienne , Mebazaa Alexandre , Cinotti Raphael 

TITLE=A network meta-analysis of therapeutic and prophylactic management of vasospasm on aneurysmal subarachnoid hemorrhage outcomes

JOURNAL=Frontiers in Neurology

VOLUME=Volume 14 - 2023

YEAR=2023

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2023.1217719

DOI=10.3389/fneur.2023.1217719

ISSN=1664-2295

ABSTRACT=Background: Vasospasm and cerebral ischemia after aneurysmal subarachnoid hemorrhage are associated with mortality and poor neurological outcome. We studied the efficacy of all available strategies targeting vasospasm and cerebral ischemia on outcomes in a network meta-analysis. 
Methods: We searched EMBASE and MEDLINE database from January 1, 1990 and November 28, 2021, according to PRISMA guidelines. Randomized controlled trials and longitudinal studies were included. All curative or preventive strategies targeting vasospasm and/or cerebral ischemia were eligible. A network meta-analysis was performed to compare all interventions with one another in a primary (randomized controlled trials only) and a secondary analysis (both trials and longitudinal studies). Mortality by 3 months was the primary outcome. Secondary outcomes were vasospasm, neurological outcome by 3 months, dichotomized as "good" or "poor" recovery according to each study definition. 
Results: 2,382 studies were screened and resulted in the selection of 192 studies (92 (47.9%) clinical trials and 100 (52.1%) cohorts) and the inclusion of 41,299 patients. In randomized controlled studies, no strategy decreased mortality by 3 months. Statins (0.79 [0.62–1]), tirilazad (0.82 [0.69–0.97]), CSF drainage (0.47 [0.29–0.77]) and clazosentan (0.51 [0.360.71]) significantly decreased the incidence of vasospasm. Cilostazol was the only treatment associated with improved neurological outcome by 3 months in the primary (OR 1.16, 95% CI [1.051.28]) and secondary analysis (OR 2.97, 95% CI [1.396.32]). 
Discussion: In the modern era of subarachnoid hemorrhage, all strategies targeting vasospasm failed to decrease mortality. Cilostazol should be confirmed as a treatment to improve neurological outcome. The link between vasospasm and neurological outcome appears questionable.
Registration. PROSPERO CRD42018116073