Dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage: association with reduced risk of clinical vasospasm and delayed cerebral ischemia

Abstract

OBJECTIVE Clinical vasospasm and delayed cerebral ischemia (DCI) are devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Several theories involving platelet activation have been postulated as potential explanations of the development of clinical vasospasm and DCI. However, the effects of dual antiplatelet therapy (DAPT; aspirin and clopidogrel) on clinical vasospasm and DCI have not been previously investigated. The objective of this study was to evaluate the effects of DAPT on clinical vasospasm and DCI in aSAH patients. METHODS Analysis of patients treated for aSAH during the period from July 2009 to April 2014 was performed in a single-institution retrospective study. Patients were divided into 2 groups: patients who underwent stent-assisted coiling or placement of flow diverters requiring DAPT (DAPT group) and patients who underwent coiling only without DAPT (control group). The frequency of symptomatic clinical vasospasm and DCI and of hemorrhagic complications was compared between the 2 groups, utilizing univariate and multivariate logistic regression. RESULTS Of 312 aSAH patients considered for this study, 161 met the criteria for inclusion and were included in the analysis (85 patients in the DAPT group and 76 patients in the control group). The risks of clinical vasospasm (OR 0.244, CI 95% 0.097-0.615, p = 0.003) and DCI (OR 0.056, CI 95% 0.01-0.318, p = 0.001) were significantly lower in patients receiving DAPT. The rates of hemorrhagic complications associated with placement of external ventricular drains and ventriculoperitoneal shunts were similar in both groups (4% vs 2%, p = 0.9). CONCLUSIONS The use of DAPT was associated with a lower risk of clinical vasospasm and DCI in patients treated for aSAH, without an increased risk of hemorrhagic complications.

Activation of Blood Coagulation After Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Trial of Rotational Thromboelastometry

“…Ultimately, this may contribute to the pathophysiology of DCI. 35 Based on our results, it seems that increasing fibrin formation and polymerisation might play a role in the pathophysiology of DCI. In clinical setting the antiplatelet therapy has failed to prevent this increased fibrin formation or reduce the incidence of DCI or mortality after aSAH.…”

“…36 Nonetheless, a recent retrospective trial showed promising result when dual antiplatelet therapy was used. 35…”

Avaliação dos Aneurismas Intracranianos Tratados no Instituto de Neurologia de Curitiba

“…A complicação de maior ocorrência neste estudo foi o vasoespasmo arterial (leve, moderado e severo), ocorrendo em 6 dos 26 casos que apresentaram complicação do aneurisma (23,0%). Dado compatível com a literatura que demonstra o mesmo como complicação mais frequente, principalmente entre os HSA por aneurismas rotos 24,25 .…”

Effect of Hepatic Artery Spasm on a Rat Model of Hepatic Ischemia‐Reperfusion Injury

“…Vasospasm refers to an abnormal contraction of blood vessels and can cause tissue ischemia or necrosis. At present, research is mainly focused on cerebral vasospasm during subarachnoid hemorrhage and coronary artery spasms . The mechanisms behind these processes are roughly similar, including the activation of protein kinase C, decreased nitric oxide, increased endothelin, intracellular changes in the calcium concentration, activation of inflammatory cells and factors, and structural changes in the spasmodic artery wall .…”