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Review
. 2023 Sep 4;46(1):221.
doi: 10.1007/s10143-023-02120-2.

Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: an updated meta-analysis

Keng Siang Lee  1   2 , Cheyenne Lee  3 , Permesh S Dhillon  4 , Ramez Kirollos  5 , Vincent D W Nga  6 , Tseng Tsai Yeo  6 , Hans Henkes  7   8 , Adam S Arthur  9 , Leonard L L Yeo  10 , Pervinder Bhogal  11
Affiliations
Review

Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: an updated meta-analysis

Keng Siang Lee et al. Neurosurg Rev. .

Abstract

Antiplatelet therapy (AT) may serve to reduce the effects of aneurysmal subarachnoid hemorrhage (aSAH)-induced pro-coagulant state in the cerebral circulation. Several studies, however, have delivered conflicting conclusions on the efficacy of AT post aSAH. Systematic searches of Medline, Embase, and Cochrane Central were undertaken on 27th March 2023. The primary outcome was delayed cerebral ischaemia (DCI). Secondary outcomes were symptomatic and angiographic vasospasm, good functional outcome (modified Rankin Scale [mRS] with scores 0-2), hemorrhagic events, and in-hospital mortality. Twenty-two studies reporting 4378 patients with aSAH were included in the meta-analysis. AT was associated with lower rates of DCI (RR=0.62, 95% CI: 0.43; 0.89), symptomatic vasospasm (RR=0.63, 95% CI: 0.46; 0.86), and moderate/severe angiographic vasospasm (RR=0.74, 95% CI: 0.65; 0.84), with no effect on hemorrhagic complications (RR=1.36, 95% CI: 0.77; 2.41). When analyzing only post-ictal use of AT, AT additionally favored rates of good functional outcomes (RR=1.18, 95% CI: 1.10; 1.26) and in-hospital mortality (RR=0.56, 95% CI: 0.39; 0.80). In the subgroup treated with cilostazol, AT was associated with lower rates of DCI (RR=0.40, 95% CI: 0.32), symptomatic vasospasm (RR=0.47, 95% CI: 0.33; 0.65), moderate/severe angiographic vasospasm (RR=0.75, 95% CI: 0.57; 0.98) and good functional outcome (RR=1.24, 95% CI: 1.08; 1.43). In the surgically treated aSAH subgroup, AT favored rates of symptomatic vasospasm (RR=0.55, 95% CI: 0.30; 0.98), moderate/severe angiographic vasospasm (RR=0.70, 95% CI: 0.54; 0.90) and good functional outcome (RR=1.23, 95% CI: 1.09; 1.41). In the endovascularly treated aSAH subgroup, AT was associated with lower rates of in-hospital mortality (RR=0.60, 95% CI: 0.41; 0.88). In aSAH patients, post-ictal AT is associated with benefits in terms of rates of DCI, vasospasm, good functional outcomes, and in-hospital mortality without an increased risk of hemorrhagic events.

Keywords: Aneurysm; Antiplatelet; Ischemia; Meta-analysis; Neuroprotection; Stroke; Subarachnoid hemorrhage; Vasospasm.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Forest plots with random-effects model, stratified by individual antiplatelets, of A delayed cerebral ischemia, B symptomatic vasospasm, C moderate/severe angiographic vasospasm, and D good functional outcome (mRS0-2)
Fig. 2
Fig. 2
Forest plots with random-effects model, stratified by individual antiplatelets, of A in-hospital mortality, and B hemorrhagic complications
Fig. 3
Fig. 3
Forest plots with random-effects model, stratified by timing of antiplatelet use, of A delayed cerebral ischemia, B symptomatic vasospasm, C moderate/severe angiographic vasospasm, and D good functional outcome (mRS0-2)
Fig. 4
Fig. 4
Forest plots with random-effects model, stratified by timing of antiplatelet use, of A in-hospital mortality, and B hemorrhagic complications
See this image and copyright information in PMC

References

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