Abstract WMP29: Hemorrhage Associated With Ventriculoperitoneal Shunt Placement in Aneurysmal Subarachnoid Hemorrhage Patients on Dual Antiplatelet Therapy: A Retrospective Analysis

Abstract

Object: Intracranial stenting and flow diversion requires the use of dual antiplatelet therapy (DAPT) to prevent in-stent thrombosis. DAPT may significantly increase the risk of hemorrhagic complications in patients who require subsequent surgical interventions. In this study, we sought to investigate whether DAPT is a risk factor for hemorrhagic complication associated with ventriculoperitoneal (VP) shunt placement in aneurysmal subarachnoid hemorrhage (aSAH) patients. Methods: Patients with aSAH who presented to our institution from July 2009 through November 2016 requiring VP shunt placement for persistent hydrocephalus were included. The rates of hemorrhagic complication associated with VP shunt placement were compared between patients who were on DAPT (Aspirin and Clopidogrel) for use of a stent or flow diverter, and patients who underwent microsurgical clipping or coiling only and were not on DAPT by way of a backward stepwise multivariate analysis. Results: 443 patients were admitted for management of aSAH. Eighty of these patients eventually required VP shunt placement. 32 patients (40%) had been treated with stent-assisted coiling or flow diverters and required DAPT, whereas 48 patients (60%) had been treated with coiling without stents or surgical clipping and were not on DAPT at the time of VP shunt placement. A total of 8 cases (10%) of new hemorrhage along the intracranial proximal catheter of the VP shunt were observed. Seven of these hemorrhages were observed in patients on DAPT, while one occurred in a patient not on DAPT. After multivariate analysis, only DAPT was significantly associated with hemorrhage [OR: 31.23, 95% CI: 2.98-327.32, p=.0001]. One hemorrhage (1 of 32 [3%]) in a patient on DAPT required shunt revision for hemorrhage-associated proximal catheter blockage. The remaining seven hemorrhages were clinically insignificant. Conclusions: Our clinical series confirms that in patients with ruptured aneurysms that are candidates for stent assisted coiling or flow diversion, the risk of clinically significant VP shunt associated hemorrhage with DAPT is low. In an era of evolving endovascular therapeutics, stenting or flow diversion is a viable option in select aSAH patients.