Safety of Early Pharmacological Thromboprophylaxis after Subarachnoid Hemorrhage

Abstract

Objective: The recent guidelines on management of aneurysmal subarachnoid hemorrhage (aSAH) advise pharmacological thromboprophylaxis (PTP) after aneurysm obliteration. However, no study has addressed the safety of PTP in the aSAH population. Therefore, the aim of this study was to assess the safety of early PTP after aSAH. Methods: Retrospective cohort of aSAH patients admitted between January 2012 and June 2013 in a single high-volume aSAH center. Traumatic SAH and perimesencephalic hemorrhage patients were excluded. Patients were grouped according to PTP timing: early PTP group (PTP within 24 hours of aneurysm treatment), and delayed PTP group (PTP started > 24 hours). Results: A total of 174 SAH patients (mean age 56.3 ± 12.5 years) were admitted during the study period. Thirty-nine patients (22%) did not receive PTP, whereas 135 patients (78%) received PTP after aneurysm treatment or negative angiography. Among the patients who received PTP, 65 (48%) had an external ventricular drain. Twenty-eight patients (21%) received early PTP, and 107 (79%) received delayed PTP. No patient in the early treatment group and three patients in the delayed PTP group developed an intracerebral hemorrhagic complication. Two required neurosurgical intervention and one died. These three patients were on concomitant PTP and dual antiplatelet therapy. Conclusions: The initiation of PTP within 24 hours may be safe after the treatment of a ruptured aneurysm or in angiogram-negative SAH patients with diffuse aneurysmal hemorrhage pattern. We suggest caution with concomitant use of PTP and dual antiplatelet agents, because it possibly increases the risk for intracerebral hemorrhage.RÉSUMÉ: Sécurité de la thromboprophylaxie pharmacologique précoce après une hémorragie sous-arachnoïdienne. Objectif: Les lignes directrices récentes sur la prise en charge de l'hémorragie sous-arachnoïdienne anévrismale (HSAa) recommandent la thromboprophylaxie pharmacologique (TPP) après l'oblitération de l'anévrisme. Cependant, aucune étude n'a examiné la sécurité de la TPP chez des patients présentant une HSAa. Le but de cette étude était donc d'évaluer la sécurité de la TPP précoce après une HSAa. Méthode: Cette étude rétrospective porte sur une cohorte de patients atteints d'une HSAa, hospitalisés entre janvier 2012 et juin 2013 dans un seul centre hospitalier à haut volume de HSAa. Les patients atteints de HSA traumatique ou d'hémorragie périmésencéphalique ont été exclus de l'étude. Les patients ont été répartis en deux groupes, selon le moment où la TPP a été administrée, soit dans les premières 24 heures ou plus de 24 heures après l'événement. Résultats: Cent soixante-quatorze patients atteints d'une HSA, dont l'âge moyen était de 56,3 ± 12,5 ans, ont été entrés dans l'étude. Trente-neuf patients (22%) n'ont pas reçu de TPP et 135 patients (78%) ont été traités par TPP après le traitement de l'anévrisme ou après une angiographie négative. Parmi les patients qui ont reçu la TPP, 65 (48%) avaient un drain ventriculaire externe. Vingt-huit...

Cerebral Angiographic Findings in Non-Traumatic Intracranial Hemorrhage: A Single Center Experience in the West of Iran

“…Aneurysm, arteriovenous malformation and cavernous malformation are the most common causes of non-traumatic intracranial hemorrhages [3][4][5]. Conventional catheter angiography is the gold standard for diagnosis of vascular abnormality; however; other imaging modalities such as CTA and MRA can help to find out about vascular abnormalities [6][7][8]. Intracranial aneurysms are the most common causes of non-traumatic intracranial hemorrhage, occurring in 60%-85% of cases [9,10].…”

Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature

“…Patients with pSAH of unknown etiology are primarily treated conservatively [7,8,14,[25][26][27]. However, SAH complications, such as acute and chronic hydrocephalus, may occur, often requiring surgical interventions, including temporary external ventricular drainage and cerebrospinal fluid shunting.…”

Managing aneurysmal subarachnoid hemorrhage: It takes a team

“…108 In a retrospective study of 170 patients, our group showed that giving drugs to prevent venous thromboembolism (unfractionated heparin 5,000 IU subcutaneously every 12 hours or dalteparin 5,000 IU subcutaneously daily), starting within 24 hours of aneurysm treatment, could be safe. 109 Fifty-eight percent of these patients had an external ventricular drain in place. One patient developed a major cerebral hemorrhagic complication and died while on unfractionated heparin; however, the patient was also on dual antiplatelet therapy with aspirin and clopidogrel.…”

“…One patient developed a major cerebral hemorrhagic complication and died while on unfractionated heparin; however, the patient was also on dual antiplatelet therapy with aspirin and clopidogrel. 109 Current guidelines suggest that intermittent compression devices be applied in all patients before aneurysm treatment. Pharmacologic thromboprophylaxis with a heparinoid can be started 12 to 24 hours after aneurysm treatment.…”

“…Pharmacologic thromboprophylaxis with a heparinoid can be started 12 to 24 hours after aneurysm treatment. 3,109 ■ A TEAM APPROACH Patients with subarachnoid hemorrhage need integrated care from different medical and nursing specialties. The best outcomes are achieved by systems that can focus as a team on the collective goal of quick intervention to secure the aneurysm, followed by measures to minimize secondary brain injury.…”