External Ventricular Drain and Hemorrhage in Aneurysmal Subarachnoid Hemorrhage Patients on Dual Antiplatelet Therapy: A Retrospective Cohort Study

Hudson, Joseph S.; Prout, Benjamin; Nagahama, Yasunori; Nakagawa, Daichi; Guerrero, Waldo R; Zanaty, Mario; Chalouhi, Nohra; Jabbour, Pascal; Dandapat, Sudeepta; Allan, Lauren; Ortega‐Gutiérrez, Santiago; Samaniego, Edgar A; Hasan, David

doi:10.1093/neuros/nyy127

Cited by 44 publications

(24 citation statements)

References 11 publications

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“…Madaelil et al reported similar rates of 57% and 2% (p=0.001) for these two groups, a finding which agrees with the existing literature that aneurysm size is a risk factor for rebleeding 18. Cohen et al emphasized the need to consider placing an external ventricular drain (EVD) prior to FD placement to lower the risk of hemorrhagic complications which are more likely to occur when an EVD is placed under dual antiplatelet therapy 19–21. In our study 20 patients (45%) had a ventriculostomy prior to FD placement.…”

Section: Discussionsupporting

confidence: 88%

Flow diversion treatment for acutely ruptured aneurysms

Brinck

Jäger

Vries

et al. 2019

J NeuroIntervent Surg

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Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and <20 mm, respectively. Follow-up angiography in 29 patients (median 9.7 months) showed complete aneurysm occlusion in 27 (93%).ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

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Section: Discussionsupporting

confidence: 88%

Flow diversion treatment for acutely ruptured aneurysms

Brinck

Jäger

Vries

et al. 2019

J NeuroIntervent Surg

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“…Despite of some minor hemorrhages from postinterventional invasive procedures under antiplatelet regimes, our findings confirmed previous findings that placement of EVDs and/or ICP probes was not associated with an increased risk of severe intracranial hemorrhage [29]. In contrast, stent-assisted coiling or flow diverters were associated with an increased risk for clinically significant PHs [15]. In such cases, sAP is frequently extended with newer antiplatelet agents such as tirofiban.…”

Section: Post-interventional Surgery and Pphsupporting

confidence: 87%

Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents

Albanna

Merkelbach

Schubert

et al. 2021

Journal of the Neurological Sciences

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Endovascular treatment of ruptured cerebral aneurysms frequently requires antiplatelet medication to prevent thromboembolism. This might raise concern regarding the risk of postprocedural hemorrhage (pH), e.g. from placement of intracranial probes. We explored the risk of PH associated with standard antiplatelet therapy (sAP: acetylsalicylic acid, and/or clopidogrel) in the context of aneurysmal subarachnoid hemorrhage (aSAH). Methods: We retrospectively reviewed a total of 146 consecutive cases with cerebral aneurysms treated between 1/2011-12/2015, and distinguished between minor (0.5 cm 3 ) -4 cm 3 ) or major (> 4 cm 3 ) PH occurring within four weeks after intervention. A separate analysis included hemorrhages related to placement of intracranial probes and drainages in the subgroup of 99 cases with such surgical interventions (pPH). Clinical outcome was assessed via Glasgow Outcome Scale (GOS) twelve months after aSAH. Results: A total of 49 cases (33.6%) in the overall sample sustained PH, there were 19 cases of pPH. Multifactorial analyses yielded sAP as an independent predictor for minor, but not major PH (p < 0.001 vs. p = 0.829), with comparable results for pPH (p = 0.001 vs. p = 0.184). sAP did not influence the clinical outcome in either group. Conclusions: sAP was associated with a higher rate of minor PH and, more specifically, of minor pPH. However, it was neither accompanied by the occurrence of major hemorrhages nor by unfavorable clinical outcome. Future prospective studies should confirm these observations and hemorrhage risks associated with extended anticoagulation regimes after complex interventions and intra-arterial vasospasm therapy should be explored in order to facilitate interdisciplinary decision-making in aSAH.

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“…Although no hemorrhage was detected in our 4 cases, the risk of procedurerelated hemorrhage should be taken seriously. However, Hudson et al (22) suggested that both antiplatelet-associated hemorrhaging and the timing between external ventricular drain placement and DAPT initiation did not appear to be clinically significant.…”

Section: Stent Deploymentmentioning

confidence: 99%

Safety and Efficacy of Endovascular Therapy for Blood Blister-Like Aneurysms: Willis Covered Stents and Double Stents Assistant Coils—A Single Center Cohort Study

Chang

Shen

et al. 2021

Front. Neurol.

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Objective: To summarize and discuss the application of Willis covered stents (WCSs) and double stent-assisted coils in the treatment of blood blister-like aneurysms (BBAs).Materials and Methods: Thirty-two patients with BBAs treated from January 2015 to October 2020 were included in the study. Among them, 18 were treated using WCSs and 14 using double stents-assisted coils. The indications for treatment, perioperative findings, and postoperative follow-up results were collected and analyzed.Results: All 32 patients had successful stent deployments. Complete aneurysm occlusion was achieved in all 18 patients treated with WCSs immediately. WCS-related adverse events included 2 cases of mild vasospasm and 4 aggressive procedure-related vasospasms during WCS deployment, a case of dissection after WCS deployment, and 1 death due to ipsilateral temporal lobe rebleeding at the sixth day after WCS deployment. In patients treated with double stent-assisted coils, there were 3 cases of neck remnants, 1 acute occlusion of the ipsilateral MCA branch, and 4 mild procedure-related intraoperative vasospasms. The mean follow-up period was 4.2±1.6 months (range 3–6 months). Follow-up imaging data were available for 25 patients (78.1%). In the first postoperative angiographic follow-up, all BBAs were completely occluded. Mild asymptomatic stent stenosis was observed in 3 patients treated with WCSs. Follow-up examination at 6 months after the employment of WCSs showed that the modified Rankin score (mRs) was 0 in 6 patients, 1 in 5 patients, 2 in 3 patients, 3 in 1 patient, 4 in 2 patients, and 6 in 1 patient. After treatment with double stents-assisted coils, the mRs was 0 in 4 patients, 1 in 5 patients, 2 in 3 patients, and 4 in 2 patients.Conclusions: WCSs and double stent-assisted coils for the treatment of BBAs are both safe and efficient. WCSs provide a higher rate of immediate occlusion; however, there was no significant difference in the long term.

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External Ventricular Drain and Hemorrhage in Aneurysmal Subarachnoid Hemorrhage Patients on Dual Antiplatelet Therapy: A Retrospective Cohort Study

Cited by 44 publications

References 11 publications

Flow diversion treatment for acutely ruptured aneurysms

Flow diversion treatment for acutely ruptured aneurysms

Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents

Safety and Efficacy of Endovascular Therapy for Blood Blister-Like Aneurysms: Willis Covered Stents and Double Stents Assistant Coils—A Single Center Cohort Study

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