Comparative Outcomes of Combined Balloon Angioplasty and Intra-arterial Calcium Channel Blockers Versus Monotherapy for Cerebral Vasospasm Management: A Systematic Review and Meta-analysis.

Aneurysmal subarachnoid hemorrhage (aSAH) often leads to cerebral vasospasm, a serious complication associated with delayed cerebral ischemia (DCI) and increased morbidity. For vasospasm management, both balloon angioplasty (BA) and intra-arterial (IA) calcium channel blockers (CCBs) are commonly used, although their combined efficacy and safety compared to monotherapy remain unclear. We conducted a systematic review and meta-analysis in accordance with Cochrane and PRISMA guidelines. Studies were included if they investigated patients with vasospasm post-aSAH treated with both BA and IA CCBs. Eight studies met inclusion criteria, comprising patients treated with BA, IA nimodipine, or IA verapamil. Combined BA with IA nimodipine significantly improved clinical outcomes compared to BA alone (OR: 0.07, 95% CI: 0.01-0.68, p = 0.02) without increasing hemorrhagic or ischemic risks. However, ischemic complications were higher with combined therapy than IA nimodipine alone (OR: 0.04, 95% CI: 0.01-0.40, p < 0.01). Combined therapy reduced retreatment rates compared to IA verapamil monotherapy (OR: 3.18, 95% CI: 1.15-8.79, p = 0.03). Our analysis indicates that combined BA and IA CCBs may improve clinical outcomes for aSAH patients with vasospasm without increasing complications compared to BA alone. However, combined therapy was associated with a significant increase in ischemic complications compared to CCB monotherapy. These findings highlight the potential role of combined therapy in select patients unresponsive to single-agent approaches and emphasize the importance of careful patient selection. Further randomized studies are necessary to confirm these findings and establish standardized guidelines for combined therapy use.