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REVIEW ARTICLE

Cerebral vasospasm after spontaneous subarachnoid hemorrhage: Pathophysiology, diagnosis, and contemporary management

Suat Demir1* ,  Buruc Erkan1 ,  Ebubekir Akpinar1 ,  Lutfi Sinasi Postalci1
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1 Department of Neurosurgery, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
Advanced Neurology, 025190049 https://doi.org/10.36922/AN025190049
Received: 6 May 2025 | Revised: 7 October 2025 | Accepted: 22 October 2025 | Published online: 7 November 2025
© 2025 by the Author(s). This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by/4.0/ )
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Abstract

Cerebral vasospasm (CV) following spontaneous subarachnoid hemorrhage is a serious complication that can lead to delayed cerebral ischemia, significantly increasing both morbidity and mortality. This article offers an in-depth examination of the pathophysiological mechanisms, risk factors, diagnostic strategies, and currently available treatment options concerning CV. Several distinct yet interconnected processes contribute to the development of vasospasm, such as oxidative stress driven by oxyhemoglobin, increased endothelin-1 activity, diminished nitric oxide availability, endothelial dysfunction, vascular inflammation, and sympathetic overactivation. In symptomatic cases, digital subtraction angiography remains the most reliable modality for diagnosis, offering detailed vascular visualization and the opportunity for concurrent therapeutic intervention. Among pharmacological agents, oral nimodipine is the only drug with proven efficacy in enhancing functional outcomes and is strongly endorsed by current clinical guidelines (Class I, Level A). In cases of refractory vasospasm, endovascular treatments such as transluminal balloon angioplasty and intra-arterial vasodilator infusion play a critical role. The management of CV requires an individualized, time-sensitive, and multimodal approach in both diagnosis and therapy. There remains a need for advanced randomized controlled trials and standardized treatment protocols in this field.

Keywords
Aneurysmal subarachnoid hemorrhage
Cerebral vasospasm
Delayed cerebral ischemia
Diagnostic imaging
Endovascular treatment
Multimodal monitoring
Nimodipine
Risk factors
Funding
None.
Conflict of interest
The authors declare they have no competing interests.
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Advanced Neurology, Electronic ISSN: 2810-9619 Print ISSN: 3060-8589, Published by AccScience Publishing
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