Effects of post-interventional antiplatelet therapy on angiographic vasospasm, delayed cerebral ischemia, and clinical outcome after aneurysmal subarachnoid hemorrhage: a single-center experience

Abstract

Platelet activation has been postulated to be involved in the pathogenesis of delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to investigate potentially beneficial effects of antiplatelet therapy (APT) on angiographic CVS, DCI-related infarction and functional outcome in endovascularly treated aSAH patients. Retrospective single-center analysis of aSAH patients treated by endovascular aneurysm obliteration. Based on the post-interventional medical regime, patients were assigned to either an APT group or a control group not receiving APT. A subgroup analysis separately investigated those APT patients with aspirin monotherapy (MAPT) and those receiving dual treatment (aspirin plus clopidogrel, DAPT). Clinical and radiological characteristics were compared between groups. Possible predictors for angiographic CVS, DCI-related infarction, and an unfavorable functional outcome (modified Rankin scale ≥ 3) were analyzed. Of 160 patients, 85 (53%) had received APT (n = 29 MAPT, n = 56 DAPT). APT was independently associated with a lower incidence of an unfavorable functional outcome (OR 0.40 [0.19–0.87], P = 0.021) after 3 months. APT did not reduce the incidence of angiographic CVS or DCI-related infarction. The pattern of angiographic CVS or DCI-related infarction as well as the rate of intracranial hemorrhage did not differ between groups. However, the lesion volume of DCI-related infarctions was significantly reduced in the DAPT subgroup (P = 0.011). Post-interventional APT in endovascularly treated aSAH patients is associated with better functional outcome at 3 months. The beneficial effect of APT might be mediated by reduction of the size of DCI-related infarctions.

Hemostasis and Fibrinolysis following Aneurysmal Subarachnoid Hemorrhage: A Systematic Review on Additional Knowledge from Dynamic Assays and Potential Treatment Targets

“…13 A recent retrospective study indicates lower incidence of unfavorable functional outcome and a reduction in lesion volume after DCI-related infarction with antiplatelet therapy following coil procedure. 18 Another small retrospective study evaluated tirofiban infusion as a bridge from coil procedure to steady state of dual-antiplatelet therapy (ASA and clopidogrel) and reported reduced odds for DCI. 78 The present review does not systematically evaluate primary hemostasis beyond the admission sample, but in the studies evaluating platelet function over time following aSAH, platelet activity and aggregation measures increased.…”

“…13 14 15 16 17 However, a recent retrospective study including only aSAH patients treated with coil procedure reveals a possible benefit on DCI from the treatment with platelet inhibitors. 18…”

“…[13][14][15][16][17] However, a recent retrospective study including only aSAH patients treated with coil procedure reveals a possible benefit on DCI from the treatment with platelet inhibitors. 18 The outcome following aSAH has markedly improved over the past 30 years as treatment has changed from open surgical clipping toward endovascular coil treatment when possible. In the early 1990s, there was a shift toward earlier surgery to secure the ruptured aneurysm.…”

Acute paraparesis syndrome after ruptured anterior communicating artery aneurysm

“…Symptomatic vasospasm was defined as a documented arterial vasospasm consistent with new neurological deficits presenting within 21 days after the onset of SAH and not explained by other causes of neurological deterioration (re-bleeding, acute or worsening hydrocephalus, electrolyte disturbances, hypoxia, or seizures). [7,15,16] All focal deficits were ascribed to the vascular territory, which could best explain the symptoms. We divided the patients into 2 groups based on the presence (n = 7) or absence (n = 203) of acute paraparesis after anterior communicating aneurysm rupture.…”

Impact of Intravenous Aspirin Administration on Ventriculostomy-Associated Hemorrhage in Coiled Acute Subarachnoid Hemorrhage Patients

“…Furthermore, post-procedural aspirin has also been shown to improve clinical outcomes in a randomized trial of clipped and coiled subarachnoid hemorrhage patients, though the mechanism for this remains uncertain. 3 Evidence for an impact on delayed ischaemic process is conflicting, [3][4][5] but there remains a school of thought that aspirin may limit the deleterious effects of at least part of this process. Nevertheless, routine use of procedural intravenous (IV) aspirin loading to compliment treatment of ruptured intracranial aneurysms remains controversial, largely owing to a presumed increase in bleeding risk.…”