Adjunctive Fasudil Use and Outcomes After Clazosentan Treatment for Aneurysmal Subarachnoid Hemorrhage: A Multicenter DCI Japan Registry Study

Background/Objectives: Subarachnoid hemorrhage (SAH) is frequently complicated by cerebral vasospasm (VS). Clazosentan reduces VS, and fasudil hydrochloride hydrate (Fasudil) is widely used for VS prevention in Japan. However, the benefit of adding Fasudil to clazosentan remains unclear. We investigated whether adjunctive Fasudil was associated with VS-related and functional outcomes in clazosentan-treated aneurysmal SAH. Methods: We retrospectively analyzed data from the multicenter “Database of Cohort Study for Outcome of SAH in Japan,” collected from 2020 to 2024. Patients with aneurysmal SAH who underwent surgical clipping or endovascular coiling within 4 days of onset and completed 14 days of clazosentan treatment were included. Outcomes were compared between clazosentan plus Fasudil and clazosentan alone. Multivariable logistic regression assessed factors associated with angiographic vasospasm (AVS), cerebral infarction, and poor functional outcome (modified Rankin Scale 3–6) at discharge and 6 months. Results: Among 341 patients, 100 (29.3%) received adjunctive Fasudil and 241 (70.7%) clazosentan alone. AVS occurred in 58/329 (17.6%), cerebral infarction in 58/327 (17.7%), poor functional outcome at discharge in 142/341 (41.6%), and poor functional outcome at 6 months in 82/325 (25.2%). Adjunctive Fasudil was independently associated with higher odds of AVS (adjusted odds ratio [aOR] 2.41, 95% confidence interval [CI] 1.21–4.81), cerebral infarction (aOR 2.10, 95% CI 1.08–4.09), and poor 6-month outcome (aOR 2.88, 95% CI 1.08–7.71), but not with poor functional outcome at discharge (aOR 1.37, 95% CI 0.62–3.03). Conclusions: In clazosentan-treated aneurysmal SAH, adjunctive Fasudil use was not associated with additional benefit and was associated with higher odds of AVS, cerebral infarction, and poor functional outcome at 6 months.