Oral Nimodipine in Aneurysmal Subarachnoid Hemorrhage: A Critical Propensity Score-Matched Reevaluation in a...

Oral nimodipine is recommended as standard therapy for aneurysmal subarachnoid hemorrhage (aSAH) based on trials from the 1980s. Given major advances in aneurysm treatment and neuro-intensive care, its effectiveness in contemporary settings warrants reevaluation.

We retrospectively analyzed consecutive patients with aSAH treated between 2015 and 2025. Clinical, radiological, and outcome data were extracted from medical records. Patients receiving prophylactic oral nimodipine (Nimo+) were compared with those who did not (Nimo-). Propensity score matching (PSM) was applied to balance baseline characteristics. Primary outcome was neurological function at discharge and at 3 months, assessed with the Glasgow Outcome Scale (GOS). Secondary outcomes included angiographic vasospasm, cerebral infarction, and mortality.

Of the 312 patients eligible for inclusion in this study, 102 received oral nimodipine and 210 did not. After PSM, 102 patients were included per group with no differences in baseline characteristics. Nimodipine was associated with lower rates of angiographic vasospasm (43% vs 64%; p < 0.001) and delayed infarction (38% vs 58%; p = 0.008) and with better GOS score at discharge (p = 0.047) and at 3 months (p = 0.008). Mortality did not differ between the two groups. Subgroup analysis showed benefits in terms of angiographic vasospasm, infarction, and functional outcome among patients receiving nimodipine ≥ 14 days, whereas shorter administration only reduced angiographic vasospasm.

In this contemporary propensity score-matched cohort, oral nimodipine therapy reduced vasospasm and delayed infarction and improved neurological outcome without having an impact on mortality. Sustained administration for at least 14 days appears to be crucial to achieve benefit, favoring full-course nimodipine therapy in aSAH management.