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J Neurosurg. 2018 Sep;129(3):702-710. doi: 10.3171/2017.5.JNS17831. Epub 2017 Nov 3.

Dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage: association with reduced risk of clinical vasospasm and delayed cerebral ischemia.

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Departments of1Neurosurgery and.
2Department of General Surgery, Mercy Medical Center, Des Moines, Iowa.
3Department of Neurosurgery, University of Tokyo, Japan.
4Department of Neurosurgery, University of Miami, Florida.
5Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania.
6Department of Neurology, Mayo Clinic, Rochester, Minnesota.
7Radiology, University of Iowa Hospitals and Clinics.
8Department of Neurology, University of Iowa College of Medicine.
9Department of Epidemiology, University of Iowa, Iowa City.
10Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio; and.
11Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.


OBJECTIVE Clinical vasospasm and delayed cerebral ischemia (DCI) are devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Several theories involving platelet activation have been postulated as potential explanations of the development of clinical vasospasm and DCI. However, the effects of dual antiplatelet therapy (DAPT; aspirin and clopidogrel) on clinical vasospasm and DCI have not been previously investigated. The objective of this study was to evaluate the effects of DAPT on clinical vasospasm and DCI in aSAH patients. METHODS Analysis of patients treated for aSAH during the period from July 2009 to April 2014 was performed in a single-institution retrospective study. Patients were divided into 2 groups: patients who underwent stent-assisted coiling or placement of flow diverters requiring DAPT (DAPT group) and patients who underwent coiling only without DAPT (control group). The frequency of symptomatic clinical vasospasm and DCI and of hemorrhagic complications was compared between the 2 groups, utilizing univariate and multivariate logistic regression. RESULTS Of 312 aSAH patients considered for this study, 161 met the criteria for inclusion and were included in the analysis (85 patients in the DAPT group and 76 patients in the control group). The risks of clinical vasospasm (OR 0.244, CI 95% 0.097-0.615, p = 0.003) and DCI (OR 0.056, CI 95% 0.01-0.318, p = 0.001) were significantly lower in patients receiving DAPT. The rates of hemorrhagic complications associated with placement of external ventricular drains and ventriculoperitoneal shunts were similar in both groups (4% vs 2%, p = 0.9). CONCLUSIONS The use of DAPT was associated with a lower risk of clinical vasospasm and DCI in patients treated for aSAH, without an increased risk of hemorrhagic complications.


ACoA = anterior communicating artery; ADP = adenosine diphosphate; ATP = adenosine triphosphate; CTA = CT angiography; DAPT = dual antiplatelet therapy; DCI = delayed cerebral ischemia; EVD = external ventricular drain; ICA = internal carotid artery; ICU = intensive care unit; MAP = mean arterial pressure; SAH = subarachnoid hemorrhage; VP = ventriculoperitoneal; aSAH = aneurysmal SAH; aneurysm rupture; aspirin; clopidogrel; coil; mRS = modified Rankin Scale; stent; vascular disorders


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