Treatment Outcomes of Clazosentan Use During the Perioperative Period for Subarachnoid Hemorrhage

Background Fasudil hydrochloride hydrate has been traditionally administered in the perioperative management of aneurysmal subarachnoid hemorrhage (aSAH) in Japan for the prevention of delayed cerebral ischemia (DCI) secondary to cerebral vasospasm. While clazosentan, a selective endothelin receptor antagonist, was introduced in April 2022 as an alternative therapeutic option for the same indication, comparative data regarding the therapeutic effectiveness between these agents remains limited. Therefore, this study investigated the differences in treatment outcomes between traditional fasudil hydrochloride hydrate and clazosentan in the perioperative management of aSAH. Materials and methods We retrospectively analyzed aSAH cases treated at our hospital from April 2020 to April 2024. Cases were stratified into either the conventional (fasudil hydrochloride hydrate) or clazosentan group. The primary endpoint was the frequency of DCI associated with cerebral vasospasm. The secondary endpoints were moderate or severe cerebral vasospasm within 14 days of aSAH onset, frequency of rescue therapy, modified Rankin scale (mRS) ≤3 at discharge and hospital stay duration. The postoperative incidence of symptomatic pulmonary edema and mortality assessed safety. Results The study analyzed 104 cases, 61 in the conventional group and 43 in the clazosentan group. The frequency of DCI did not differ between the conventional and clazosentan groups (three cases vs. one case, respectively). Similarly, no significant differences were observed in moderate or severe cerebral vasospasm, rescue therapy, or hospital stay duration. The conventional group had 29 cases with mRS ≤3 at discharge compared with 31 in the clazosentan group. A significantly higher incidence of symptomatic pulmonary edema was observed in the clazosentan group, with 15 cases vs. eight cases in the conventional group. No difference was observed in mortality at discharge. Conclusions We compared treatment outcomes between fasudil hydrochloride hydrate and clazosentan for aSAH. While clazosentan showed a non-significant trend toward lower DCI frequency, it was associated with increased symptomatic pulmonary edema. Given the study's limitations, larger-scale research with matched baseline characteristics is needed to definitively evaluate these agents' comparative efficacy.