When should subarachnoid hemorrhage (SAH) be treated with Nimodipine (nimodipine)?

From the Guidelines

Nimodipine should be administered to all patients with aneurysmal subarachnoid hemorrhage (SAH) as soon as the diagnosis is confirmed, ideally within 96 hours of symptom onset, at a dose of 60 mg orally every 4 hours for 21 consecutive days, as recommended by the most recent guidelines 1.

Key Considerations

• The standard regimen of nimodipine is 60 mg orally every 4 hours for 21 consecutive days, which can be adjusted if the patient cannot swallow or has hypotension 1.
• Nimodipine works by blocking calcium channels in cerebral blood vessels, preventing cerebral vasospasm and secondary brain injury 1.
• Blood pressure should be monitored during administration, particularly with the first few doses, to ensure the patient does not develop significant hypotension 1.
• Nimodipine therapy should continue for the full 21-day course even if the patient undergoes surgical clipping or endovascular coiling of the aneurysm, as the risk of vasospasm persists throughout this period 1.

Administration and Monitoring

• If the patient cannot swallow, the liquid contents of the capsule can be extracted and administered through a nasogastric tube 1.
• In patients with hypotension, the dose may be reduced to 30 mg 1.
• The patient's blood pressure and neurological status should be closely monitored during nimodipine administration 1.

Evidence-Based Recommendations

• The 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage recommends early initiation of enteral nimodipine to prevent delayed cerebral ischemia and improve functional outcomes 1.
• The Canadian Stroke Best Practice Recommendations also support the use of nimodipine in patients with SAH, ideally within 96 hours of symptom onset 1.

From the FDA Drug Label

Oral nimodipine capsules therapy should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage. Nimodipine should be treated for subarachnoid hemorrhage (SAH) as soon as possible, within 96 hours of the onset of SAH.

• The recommended oral dose is 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days.
• Key considerations for treatment include close monitoring of blood pressure and heart rate, especially in patients with severely disturbed liver function or those taking strong inhibitors or inducers of CYP3A4 2.

From the Research

Treatment of Subarachnoid Hemorrhage with Nimodipine

• Subarachnoid hemorrhage (SAH) is a life-threatening condition that can lead to cerebral vasospasm, resulting in high morbidity and mortality 3, 4, 5, 6, 7.
• Nimodipine, a calcium channel blocker, is commonly used to prevent cerebral vasospasm after SAH 3, 4, 5, 6, 7.

Efficacy of Nimodipine in Preventing Cerebral Vasospasm

• Studies have shown that nimodipine can reduce the incidence of cerebral vasospasm after SAH, although the results are not always consistent 3, 4, 5, 6, 7.
• A systematic review and meta-analysis found that intraventricular nimodipine was associated with a lower risk of angiographic vasospasm compared to oral nimodipine 3.
• Another study found that there was no significant difference in the incidence of delayed ischemic neurological deficits (DINDs) between patients receiving peroral or intravenous nimodipine 4.

Safety and Tolerability of Nimodipine

• Nimodipine is generally well-tolerated, although it can cause hypotension, particularly in children 5, 6.
• A study in children with SAH found that oral nimodipine was associated with a high rate of hypotension requiring intervention or dose modification 5.
• Another study found that prophylactic nimodipine did not reduce the incidence of vasospasm in children with SAH, but may improve short-term brain function without significant safety issues 6.

Clinical Use of Nimodipine

• Nimodipine should be considered for use in patients with SAH to prevent cerebral vasospasm, although the optimal route of administration and dosage are still debated 3, 4, 5, 6, 7.
• The decision to use nimodipine should be based on individual patient factors, including the severity of SAH, the presence of vasospasm, and the patient's overall medical condition 3, 4, 5, 6, 7.