Effects of post-interventional antiplatelet therapy on angiographic vasospasm, delayed cerebral ischemia, and clinical outcome after aneurysmal subarachnoid hemorrhage: a single-center experience

Claudia Ditz,Volker M Tronnier,Hannes Schacht,Peter Schramm,Alexander Neumann,Jan Küchler,Björn Machner

doi:10.1007/s10143-021-01477-6

Claudia Ditz, Volker M Tronnier + Show 5 more

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https://doi.org/10.1007/s10143-021-01477-6

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Abstract

Platelet activation has been postulated to be involved in the pathogenesis of delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to investigate potentially beneficial effects of antiplatelet therapy (APT) on angiographic CVS, DCI-related infarction and functional outcome in endovascularly treated aSAH patients. Retrospective single-center analysis of aSAH patients treated by endovascular aneurysm obliteration. Based on the post-interventional medical regime, patients were assigned to either an APT group or a control group not receiving APT. A subgroup analysis separately investigated those APT patients with aspirin monotherapy (MAPT) and those receiving dual treatment (aspirin plus clopidogrel, DAPT). Clinical and radiological characteristics were compared between groups. Possible predictors for angiographic CVS, DCI-related infarction, and an unfavorable functional outcome (modified Rankin scale ≥ 3) were analyzed. Of 160 patients, 85 (53%) had received APT (n = 29 MAPT, n = 56 DAPT). APT was independently associated with a lower incidence of an unfavorable functional outcome (OR 0.40 [0.19–0.87], P = 0.021) after 3 months. APT did not reduce the incidence of angiographic CVS or DCI-related infarction. The pattern of angiographic CVS or DCI-related infarction as well as the rate of intracranial hemorrhage did not differ between groups. However, the lesion volume of DCI-related infarctions was significantly reduced in the DAPT subgroup (P = 0.011). Post-interventional APT in endovascularly treated aSAH patients is associated with better functional outcome at 3 months. The beneficial effect of APT might be mediated by reduction of the size of DCI-related infarctions.

Highlights

Delayed cerebral ischemia (DCI) is a severe complication after aneurysmal subarachnoid hemorrhage and represents the most important predictor of mortality and morbidity in patients who survive the acute bleeding event [18, 37]
After excluding 29 patients due to the above-mentioned exclusion criteria, 160 patients with aneurysmal subarachnoid hemorrhage (aSAH) and endovascular aneurysm treatment were included in the final analysis
Eighty-five patients (53%) received antiplatelet therapy (APT) (APT group), 1/3 of them had aspirin monotherapy (n = 29/85) and 2/3 a DAPT consisting of aspirin and clopidogrel (n = 56/85)

Summary

Introduction

Delayed cerebral ischemia (DCI) is a severe complication after aneurysmal subarachnoid hemorrhage (aSAH) and represents the most important predictor of mortality and morbidity in patients who survive the acute bleeding event [18, 37]. Endothelial damage from aneurysm rupture leads to immediate platelet activation and aggregation with consecutive release of cytokines and vasoactive substances from within the platelet granules. These processes do cause vasoconstriction and the formation of microthrombi and contribute to the activation of inflammation [48]. An increased platelet activity after aSAH with consecutive release of thromboxane A2 was found to be associated with DCI and the occurrence of angiographic CVS [25, 26, 31]. Previous studies suggest that microthrombi/-emboli play an essential role in the development of DCI-related infarction [34, 41, 42, 48]

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