Efficacy and safety of balloon Angioplasty and Intra-Arterial calcium channel blockers in the management of Cerebral Vasospasm: a systematic review and meta-analysis.

Cerebral vasospasm is a leading cause of delayed cerebral ischemia following subarachnoid hemorrhage (SAH), often resulting in high morbidity and mortality. While balloon angioplasty (BA) and intra-arterial calcium channel blockers (IA CCBs) are utilized for vasospasm management, their efficacy and safety remain unclear. We systematically searched PubMed, Scopus, and Web of Science for studies reporting on BA or IA CCB treatment for cerebral vasospasm up to October 2024, following PRISMA guidelines. Seventy studies met the inclusion criteria. BA was associated with a clinical improvement rate of 65% and favorable outcomes in 51% of patients. Hemorrhagic complications occurred in 1.5%, ischemic complications in 5%, and the mortality rate was 20%. Radiological improvement was achieved in 93% of BA cases, with a retreatment rate of 11%. Nimodipine showed clinical improvement in 56% of cases and favorable outcomes in 57%, with a 16% rate of ischemic complications and a mortality rate of 14%. Nicardipine had the highest rates of clinical improvement (73.5%) and favorable outcomes (85%), with a mortality rate of 6%. Verapamil showed clinical improvement in 44% of cases and a mortality rate of 17%. Retreatment rates were 26% for nimodipine, 46% for nicardipine, and 45% for verapamil. BA and IA CCBs are both effective in treating cerebral vasospasm. BA provides high radiological improvement but is associated with high complication and mortality rates. IA CCBs, particularly nicardipine, offer good clinical and radiological outcomes with lower complication rates but require more frequent retreatments. Further randomized trials are needed to optimize treatment strategies.