Ventriculostomy-related intracranial hemorrhage following surgical and endovascular treatment of ruptured aneurysms

Abstract

Endovascular therapy of ruptured aneurysms is regularly accompanied by periprocedural heparinization and requires the use of periprocedural antiplatelets in more complex cases. This raises concerns regarding increased bleeding risks in the case of frequently required ventriculostomy. The aim of this study was to analyze risk factors for ventriculostomy-related intracranial hemorrhages (VS-ICH) in endovascular or surgical treatment of ruptured aneurysms with a focus on antithrombotic therapy. In this retrospective analysis, we included patients admitted to our institution over a 12-year period who had received at least one ventriculostomy due to subarachnoid hemorrhage-related hydrocephalus. Patients were dichotomized into an endovascular and surgical group and rates of VS-ICH were compared. Risk factors for VS-ICH were assessed in uni- and multivariate analyses. A total of 606 ventriculostomies were performed in 328 patients. Within the endovascular group, antiplatelet therapy was used in 44.8% of cases. The overall rate of ventriculostomy-related intracranial hemorrhage was 13.1%. Endovascular treatment was associated with a higher rate of VS-ICH compared to surgical treatment (p = 0.011), but not in cases without antiplatelet therapy (p = 0.166). Application of any antiplatelet therapy (odds ratio, 2.647 [95% confidence interval, 1.141–6.143]) and number of ventriculostomies (odds ratio, 2.513 [95% confidence interval, 1.859–3.395]) were independent predictors of ventriculostomy-related hemorrhages. Our findings indicate an increased risk of VS-ICH in the endovascular group if administration of antiplatelets was required. While this aspect has to be included into treatment decision-making, it must be weighed against the benefits of endovascular techniques.

Safety of dual antiplatelet therapy in the acute phase of aneurysmal subarachnoid hemorrhage: a propensity score–matched study

“…9 In previous studies, the rate of EVD-related hemorrhage has varied between 0% and 60% following placement of an EVD in patients who have received antiplatelets. 6,7,10,11 In a meta-analysis, Cagnazzo et al 7 reported EVD-related hemorrhage in 21% of patients who had received antiplatelet therapy, a significantly higher rate compared with that in patients who had not received antiplatelet therapy. Similarly, our patients in the DAPT group had a higher incidence of EVD-related hemorrhage than those in the non-DAPT group (40.0% vs 5.9%, p = 0.023).…”

“…Moreover, there is usually a debate about the adverse effect of DAPT in other neurosurgical procedures, such as external ventricular drain (EVD) placement or removal, decompressive craniectomy, and any other craniotomies, which are common in the management of SAH. 5,6 In this study, we evaluated the safety of DAPT in the setting of acute aneurysmal SAH based on a propensity score matching (PSM) study comparing hemorrhagic and ischemic complications between patients treated with SAC or FDs and requiring DAPT and patients treated with coiling but no antiplatelet regimen.…”