Ventriculostomy-related hemorrhage in patients on antiplatelet therapy for endovascular treatment of acutely ruptured intracranial aneurysms. A meta-analysis

Abstract

The risk of ventriculostomy-related hemorrhage among patients requiring antiplatelet therapy (AT) for the endovascular treatment of acutely ruptured intracranial aneurysms needed further investigation. The authors performed a systematic review and meta-analysis of the literature examining the EVD-related hemorrhage rate among patients with and without AT (controls). According to PRISMA guidelines, a comprehensive review of studies published between January 1990 and April 2018 was carried out. The authors identified series with > 5 patients reporting the EVD-associated hemorrhage rate among the AT group and the control group. Variables influencing outcomes were analyzed using a random-effects meta-analysis model. We included 13 studies evaluating 516 (with AT) and 647 (without AT) patients requiring ventriculostomy. EVD-related hemorrhage rates were higher among the AT group (125/516 = 20.9%, 95% CI = 11.9-30%, I = 90% vs 57/647 = 9%, 95% CI = 5.5-12.5%, I = 45.8%) (p < 0.0001). Major EVD-associated hemorrhage rates were low in both the AT and control group (25/480 = 4.4%, 95% CI = 1.7-7.7%, I = 53.9% vs 6/647 = 0.7%, 95% CI = 0.03-1.7%, I = 0%) (p < 0.0001). Ventriculostomy before embolization and intraprocedural AT were associated with lower rates of EVD-related bleeding (32/230 = 9.6%, 95% CI = 2.1-17.1%, I = 75.4% vs 6/24 = 25.1%, 95% CI = 8.8-41%, I = 0%) (p < 0.02). The rate of major hemorrhage was higher after dual AT (CP + ASA) compared to single AT (ASA or CP) used as an intraprocedural loading dose (13/173 = 7%, 95% CI = 3.3-10.7%, I = 0% vs 6/210 = 1.7%, 95% CI = 0.1-3.4%, I = 0%) (p < 0.009). AT during endovascular treatment of acutely ruptured intracranial aneurysms increases the risk of EVD-related hemorrhages, although most of them are small and asymptomatic. When ventriculostomy is performed before endovascular procedures requiring antiplatelet administration, the hemorrhagic risk is minimized. A single antiplatelet therapy is associated with a lower rate of major bleeding than a dual therapy.

Neuroform Atlas stent-assisted coiling of ruptured intracranial aneurysms: A multicenter study

“…Periprocedural thrombosis, and subsequent antiGP2b3a administration remains a risk factor for ischemic complications. Regarding maintenance therapy, although DAPT is more protective against ischemic events after SAC [29,30], it is probably more dangerous, in particular with loading doses [31,32]. The optimal balance between thrombosis and hemorrhage remains unknown; this study states the low risk of ischemic complications in both SAPT and DAPT regimens and may be useful to tailor the treatment on a singlepatient basis.…”

Safety of stent-assisted coiling for the treatment of wide-necked ruptured aneurysm: A systematic literature review and meta-analysis of prevalence

“…Another finding by Cagnazzo et al, later confirmed by Lim et al, was that performing EVD before endovascular coiling was effective at minimizing the risk of ventriculostomy-related hemorrhagic complications and was not associated with a higher risk of rebleeding or other EVD-related complications, but anti-platelet therapy and stent placement are still independent risk factors for hemorrhagic complications. 51,52 Nonetheless, Roh et al discovered that SAC patients only have a slightly higher, but clinically insignificant, rate of EVD-related hemorrhagic complications compared to endovascular coiling alone and that stent use is not an independent risk factor for EVD-related hemorrhage. 33 In our systematic review, 245 EVDs were inserted and resulted in 33 (13.5%) EVD-related hemorrhages compared to the 10% EVD-related hemorrhage reported by Bodily et al 41 Most articles did not specify if the EVDrelated hemorrhages occurred in those who received EVD before stenting or after stenting, thus we could not determine if there was a temporal relationship between EVD-related hemorrhage and stenting.…”

Pipeline shield with single antiplatelet therapy in aneurysmal subarachnoid haemorrhage: multicentre experience

“…However, the use of intravascular stents, and, in particular, the high metal-density flow diverters, requires the use of DAPT to prevent stent thrombosis and ischaemic complications. This, in turn, increases the risk and severity of haemorrhagic complications in patients with acutely ruptured aneurysms 8. The phosphorylcholine coating of the PED-Shield device has been shown to reduce platelet adhesion and activation 9.…”