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

Abstract

OBJECTIVE With the evolution of neuroendovascular treatments, there is a great trend to treat acutely ruptured wide-necked aneurysms with stent-assisted coiling (SAC) and flow diverters (FDs), which inevitably requires dual antiplatelet therapy (DAPT). This therapy can increase the rate of hemorrhagic complications following other neurosurgical maneuvers, such as external ventricular drain (EVD) placement or removal. In this study, the authors aimed to evaluate the safety of DAPT in patients with aneurysmal subarachnoid hemorrhage (SAH) treated with SAC or FDs and the therapy’s potential benefit in reducing cerebral ischemia and cerebral vasospasm. METHODS In this retrospective study, the authors reviewed the records of patients who had been admitted to their hospital with acute aneurysmal SAH and treated with SAC, FDs, and/or coiling between 2012 and 2022. Patients were classified into two groups: a DAPT group, including patients who had received DAPT for SAC or FDs, and a non-DAPT group, including patients who had not received any antiplatelet regimen and had been treated with coiling. Perioperative hemorrhagic and ischemic complications and clinical outcomes were compared between the two groups. RESULTS From among 938 cases of acute ruptured aneurysms treated during 10 years of study, 192 patients were included in this analysis, with 96 patients in each treatment group, after propensity score matching. All basic clinical and imaging characteristics were equivalent between the two groups except for the neck size of aneurysms (p < 0.001). EVD-related hemorrhage was significantly higher in the DAPT group than in the non-DAPT group (p = 0.035). In most patients, however, the EVD-related hemorrhage was insignificant. Parent artery or stent-induced thrombosis was higher in the DAPT group than in the non-DAPT group (p = 0.003). The rate of cerebral ischemia was slightly lower in the DAPT group than in the non-DAPT group (11.5% vs 15.6%, p = 0.399). In the multivariate analysis, cerebral ischemia, rebleeding before securing the aneurysm, extracranial hemorrhage, and cerebral vasospasm were the predictive factors of a poor clinical outcome (p < 0.001, p < 0.001, p = 0.038, and p = 0.038, respectively). CONCLUSIONS The DAPT regimen may be safe in the setting of acute aneurysmal SAH. Although EVD-related hemorrhage is more common in the DAPT group than the non-DAPT group, it is usually insignificant without any neurological deficit.

Perioperative complications of arteriovenous tirofiban administration versus oral dual antiplatelet therapy for stent‐assisted embolization treated aneurysmal subarachnoid hemorrhage: A retrospective, controlled cohort analysis

“…Before the application of new platelet surface GP IIb/IIIa receptor antagonists such as tirofiban and abciximab in the endovascular therapy of intracranial aneurysms, a 3–5 day preoperative oral dual antiplatelet drug was often used to prevent perioperative TEs in patients with unruptured intracranial aneurysms. Present research supports the safety and efficacy of a loading dose of DAPT in preventing perioperative thrombotic events during endovascular treatment of ruptured intracranial aneurysms with stent assistance(Qoorchi Moheb Seraj et al., 2023 ). While the primary method for preventing perioperative TEs in endovascular therapy for patients with acutely ruptured aneurysms is preoperative oral DAPT, the rate of perioperative TEs is still high, ranging from approximately 8.33% to 13.21% (Wang et al., 2020 ; Zi‐Liang et al., 2017 ).…”

Safety and effectiveness of LEO stents for dual stent-assisted embolization combined with IA and IV intra-procedural infusion of tirofiban in the treatment of wide-necked intracranial bifurcation aneurysms

“…However, after the implantation of two braided stents in the aneurysm-carrying artery, the blood flow in the aneurysm capsule decreases, which facilitates thrombosis in the aneurysm capsule but increases the risk of perioperative TEs. Previously, perioperative thromboembolic events (TEs) were prevented through oral dual antiplatelet therapy, yet the incidence of perioperative TEs remained as high as 11.5% ( 5 , 10 ). In our center, perioperative TEs were prevented by oral dual antiplatelet therapy combined with IA and IV intra procedural infusion of tirofiban.…”