Antiplatelet therapy and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

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  • 1 Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts;
  • | 2 Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia;
  • | 3 Department of Neurology, University of Virginia Health System, Charlottesville, Virginia;
  • | 4 Department of Neurosurgery, University of Miami, Miami, Florida;
  • | 5 Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky; and
  • | 6 Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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OBJECTIVE

Delayed cerebral ischemia (DCI) is a potentially preventable cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The authors performed a meta-analysis to assess the effect of antiplatelet therapy (APT) on DCI in patients with aSAH.

METHODS

A systematic review of the PubMed and MEDLINE databases was performed. Study inclusion criteria were 1) ≥ 5 aSAH patients; 2) direct comparison between aSAH management with APT and without APT; and 3) reporting of DCI, angiographic, or symptomatic vasospasm rates for patients treated with versus without APT. The primary efficacy outcome was DCI. The outcomes of the APT versus no-APT cohorts were compared. Bias was assessed using the Downs and Black checklist.

RESULTS

The overall cohort comprised 2039 patients from 15 studies. DCI occurred less commonly in the APT compared with the no-APT cohort (pooled = 15.9% vs 28.6%; OR 0.47, p < 0.01). Angiographic (pooled = 51.6% vs 68.7%; OR 0.46, p < 0.01) and symptomatic (pooled = 23.6% vs 37.7%; OR 0.51, p = 0.01) vasospasm rates were lower in the APT cohort. In-hospital mortality (pooled = 1.7% vs 4.1%; OR 0.53, p = 0.01) and functional dependence (pooled = 21.0% vs 35.7%; OR 0.53, p < 0.01) rates were also lower in the APT cohort. Bleeding event rates were comparable between the two cohorts. Subgroup analysis of cilostazol monotherapy compared with no APT demonstrated a lower DCI rate in the cilostazol cohort (pooled = 10.6% vs 28.1%; OR 0.31, p < 0.01). Subgroup analysis of surgically treated aneurysms demonstrated a lower DCI rate for the APT cohort (pooled = 18.4% vs 33.9%; OR 0.43, p = 0.02).

CONCLUSIONS

APT is associated with improved outcomes in aSAH without an increased risk of bleeding events, particularly in patients who underwent surgical aneurysm repair and those treated with cilostazol. Although study heterogeneity is the most significant limitation of the analysis, the findings suggest that APT is worth exploring in patients with aSAH, particularly in a randomized controlled trial setting.

ABBREVIATIONS

APT = antiplatelet therapy; aSAH = aneurysmal subarachnoid hemorrhage; DCI = delayed cerebral ischemia; OKY-046 = (E)-3-[4-(1-imidazolylmethyl)phenyl]-2-propenoic acid hydrochloride monohydrate; RCT = randomized controlled trial; WFNS = World Federation of Neurosurgical Societies.

Supplementary Materials

    • Supplemental Tables and Figures (PDF 2,316 KB)

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