scholarly journals Hemorrhage associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on a regimen of dual antiplatelet therapy: a retrospective analysis

2018 ◽  
Vol 129 (4) ◽  
pp. 916-921 ◽  
Author(s):  
Joseph S. Hudson ◽  
Yasunori Nagahama ◽  
Daichi Nakagawa ◽  
Robert M. Starke ◽  
Brian J. Dlouhy ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Subarachnoid Hemorrhage ◽  
Dual Antiplatelet Therapy ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Flow Diversion ◽  
Shunt Revision ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Hemorrhagic Complications ◽  
The Difference

OBJECTIVEIntracranial stenting and flow diversion require 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, the authors sought to investigate whether DAPT is a risk factor for hemorrhagic complications associated with ventriculoperitoneal (VP) shunt placement in patients with aneurysmal subarachnoid hemorrhage (aSAH). Moreover, the authors sought to compare VP shunt complication rates with respect to the shunt’s location from the initial external ventricular drain (EVD) site.METHODSPatients with aSAH who presented to the authors’ institution from July 2009 through November 2016 and required VP shunt placement for persistent hydrocephalus were included. The rates of hemorrhagic complications associated with VP shunt placement were compared between patients who were on a regimen of 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 using a backward stepwise multivariate analysis. Rates of radiographic hemorrhage and infection-related VP shunt revision were compared between patients who underwent VP shunt placement along the same track and those who underwent VP shunt placement at a different site (contralateral or posterior) from the initial EVD.RESULTSA total of 443 patients were admitted for the management of aSAH. Eighty of these patients eventually required VP shunt placement. Thirty-two 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 were observed along the intracranial proximal catheter of the VP shunt. Seven of these hemorrhages were observed in patients on DAPT, and 1 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 = 0.0001). One patient (3%) on DAPT who experienced hemorrhage required shunt revision for hemorrhage-associated proximal catheter blockage. The remaining 7 hemorrhages were clinically insignificant. The difference in rates of hemorrhage between shunt placement along the same track and placement at a different site of 0.07 was not significant (6/47 vs 2/32, p = 0.46). The difference in infection-related VP shunt revision rate was not significantly different (1/47 vs 3/32, p = 0.2978).CONCLUSIONSThis clinical series confirms that, in patients with ruptured aneurysms who 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.

Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy

2013 ◽  
Vol 119 (4) ◽  
pp. 937-942 ◽  
Author(s):  
Kelly B. Mahaney ◽  
Nohra Chalouhi ◽  
Stephanus Viljoen ◽  
Janel Smietana ◽  
David K. Kung ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Acetylsalicylic Acid ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Intracranial Hemorrhages ◽  
Surgical Clipping ◽  
Vp Shunt ◽  
Hemorrhagic Complications ◽  
Clinically Significant

Object The use of an intracranial stent requires dual antiplatelet therapy to avoid in-stent thrombosis. In this study, the authors sought to investigate whether the use of dual antiplatelet therapy is a risk factor for hemorrhagic complications in patients undergoing permanent ventriculoperitoneal (VP) shunt for hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH). Methods Patients were given 325 mg acetylsalicylic acid and 600 mg clopidogrel during the coil/stent procedure, and they were maintained on dual antiplatelet therapy with acetylsalicylic acid 325 mg daily and clopidogrel 75 mg daily during hospitalization and for 6 weeks posttreatment. Patients underwent placement of VP shunt at a later time during initial hospitalization, usually between 7 and 21 days following aSAH. Postoperative CT scans obtained in each study patient were reviewed for hemorrhages related to placement of the VP shunt. Results A total of 206 patients were admitted to the University of Iowa Hospitals and Clinics with aSAH between July 2009 and October 2010. Thirty-seven of these patients were treated with a VP shunt for persistent hydrocephalus. Twelve patients (32%) had previously undergone stent-assisted coiling and were on dual antiplatelet therapy with acetylsalicylic acid and clopidogrel. The remaining 25 patients (68%) had undergone surgical clipping or aneurysm coiling and were not receiving antiplatelet therapy at the time of surgery. Four cases (10.8%) of new intracranial hemorrhages associated with VP shunt placement were observed. All 4 hemorrhages (33%) occurred in patients on dual antiplatelet therapy for stent-assisted coiling. No new intracranial hemorrhages were observed in patients not receiving dual antiplatelet therapy. The difference in hemorrhagic complications between the 2 groups was statistically significant (4 [33%] of 12 vs 0 of 25, p = 0.0075]). All 4 hemorrhages occurred along the tract of the ventricular catheter. Only 1 hemorrhage (1 [8.3%] of 12) was clinically significant as it resulted in occlusion of the proximal shunt catheter and required revision of the VP shunt. The patient did not suffer any permanent morbidity related to the hemorrhage. The remaining 3 hemorrhages were not clinically significant. Conclusions This small clinical series suggests that placement of a VP shunt in patients on dual antiplatelet therapy may be associated with an increased, but low, rate of symptomatic intracranial hemorrhage. It appears that in patients who are poor candidates for open surgical clipping and have aneurysms amenable to stent-assisted coiling, the risk of symptomatic hemorrhage may be an acceptable trade-off for avoiding risks associated with discontinuation of antiplatelet therapy. The authors' results are preliminary, however, and require confirmation in larger studies.

Risk of ventriculostomy-related hemorrhage in patients with acutely ruptured aneurysms treated using stent-assisted coiling

2011 ◽  
Vol 114 (4) ◽  
pp. 1021-1027 ◽  
Author(s):  
David K. Kung ◽  
Bruno A. Policeni ◽  
Ana W. Capuano ◽  
James D. Rossen ◽  
Pascal M. Jabbour ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Antiplatelet Agents ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Ruptured Aneurysms ◽  
Hemorrhagic Complications ◽  
Group 2 ◽  
Group 1

Object Intracranial stenting has improved the ability to treat wide-neck aneurysms via endovascular techniques. However, stent placement necessitates the use of antiplatelet agents, and the latter may complicate the treatment of patients with acutely ruptured aneurysms who demonstrate hydrocephalus and require ventriculostomy. Antiplatelet agents in this setting could increase the incidence of ventriculostomy-related hemorrhagic complications, but there are insufficient data in the medical literature to quantify this potential risk. The aim of this study was to directly quantify the risk of ventriculostomy-related hemorrhage in patients with acute aneurysmal subarachnoid hemorrhage treated with stent-assisted coiling. Methods The authors retrospectively identified 131 patients who underwent endovascular treatment for an acutely ruptured aneurysm as well as ventriculostomy or ventriculoperitoneal (VP) shunt placement. The rate of hemorrhagic complications associated with ventriculostomy or VP shunt insertion was compared between patients who underwent coiling without a stent (Group 1) and those who underwent stent-assisted coiling and dual antiplatelet therapy (Group 2). Results One hundred nine ventriculostomies or VP shunt placement procedures were performed in 91 patients in Group 1, and 50 procedures were undertaken in 40 patients in Group 2. The rates of radiographic hemorrhage and symptomatic hemorrhage were significantly higher in Group 2 (32% vs 14.7%, p = 0.02; and 8% vs 0.9%, p = 0.03, respectively). On multivariate analyses, Group 2 had 3.42 times the odds of a radiographic hemorrhage (95% CI 1.46–8.04, p = 0.0048) after adjusting for antiplatelet use prior to admission. Conclusions The application of dual antiplatelet therapy in stent-assisted coiling of acutely ruptured aneurysms is associated with an increase in the risk of hemorrhagic complications following ventriculostomy or VP shunt placement, as compared with its use in a coiling procedure without a stent.

scholarly journals Reduction of shunt dependency rates following aneurysmal subarachnoid hemorrhage by tandem fenestration of the lamina terminalis and membrane of Liliequist during microsurgical aneurysm repair

2018 ◽  
Vol 129 (5) ◽  
pp. 1166-1172 ◽  
Author(s):  
Ethan A. Winkler ◽  
Jan-Karl Burkhardt ◽  
W. Caleb Rutledge ◽  
Jonathan W. Rick ◽  
Carlene P. Partow ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Surgical Repair ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
External Ventricular Drain ◽  
Number Needed To Treat ◽  
Lamina Terminalis ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Fisher Grade ◽  
Shunt Dependency

OBJECTIVEShunt-dependent hydrocephalus is an important cause of morbidity following aneurysmal subarachnoid hemorrhage (aSAH) in excess of 20% of cases. Hydrocephalus leads to prolonged hospital and ICU stays, well as to repeated surgical interventions, readmissions, and complications associated with ventriculoperitoneal (VP) shunts, including shunt failure and infection. Whether variations in surgical technique at the time of aneurysm treatment may modify rates of shunt dependency remains a matter of debate. Here, the authors report on their experience with tandem fenestration of the lamina terminalis (LT) and membrane of Liliequist (MoL) at the time of open microsurgical repair of the ruptured aneurysm.METHODSThe authors conducted a retrospective review of 663 consecutive patients with aSAH treated from 2005 to 2015 by open microsurgery via a pterional or orbitozygomatic craniotomy by the senior author (M.T.L.). Data collected from review of the electronic medical record included age, Hunt and Hess grade, Fisher grade, need for an external ventricular drain, and opening pressure. Patients were stratified into those undergoing no fenestration and those undergoing tandem fenestration of the LT and MoL at the time of surgical repair. Outcome variables, including VP shunt placement and timing of shunt placement, were recorded and statistically analyzed.RESULTSIn total, shunt-dependent hydrocephalus was observed in 15.8% of patients undergoing open surgical repair following aSAH. Tandem microsurgical fenestration of the LT and MoL was associated with a statistically significant reduction in shunt dependency (17.9% vs 3.2%, p < 0.01). This effect was confirmed with multivariate analysis of collected variables (multivariate OR 0.09, 95% CI 0.03–0.30). Number-needed-to-treat analysis demonstrated that tandem fenestration was required in approximately 6.8 patients to prevent a single VP shunt placement. A statistically significant prolongation in days to VP shunt surgery was also observed in patients treated with tandem fenestration (26.6 ± 19.4 days vs 54.0 ± 36.5 days, p < 0.05).CONCLUSIONSTandem fenestration of the LT and MoL at the time of open microsurgical clipping and/or bypass to secure ruptured anterior and posterior circulation aneurysms is associated with reductions in shunt-dependent hydrocephalus following aSAH. Future prospective randomized multicenter studies are needed to confirm this result.

Early Ventriculoperitoneal Shunt Placement After Severe Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
2010 ◽  
Vol 66 (5) ◽  
pp. 904-909 ◽  
Author(s):  
Dong-Hun Kang ◽  
Jaechan Park ◽  
Seong-Hyun Park ◽  
Yong-Sun Kim ◽  
Sung-Kyoo Hwang ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Volume Ratio ◽  
External Ventricular Drainage ◽  
Mean Value ◽  
Vp Shunt ◽  
Poor Grade ◽  
Shunt Placement ◽  
Fisher Grade ◽  
The Mean

Abstract OBJECTIVE This study investigated the outcome of early shunt placement in patients with poor-grade subarachnoid hemorrhage and the effect of intraventricular hemorrhage (IVH) and high proteinaceous cerebrospinal fluid (CSF) on subsequent shunt performance. METHODS This study included 33 consecutive patients with initial Fisher grade (3/4) subarachnoid hemorrhage who had undergone conversion from external ventricular drainage (EVD) to a ventriculoperitoneal (VP) shunt and whose computed tomography scan showed IVH at the time of shunt placement. Early weaning from an EVD and conversion to a VP shunt was performed irrespective of IVH or high protein content in the CSF. RESULTS The mean interval from EVD to VP shunt placement was 6.4 days. The mean volume of IVH was 9.44 mL, and the mean value of IVH/whole ventricle volume ratio (ie, percentage of blood suspension in the CSF) was 9.81%. The mean perioperative protein level in the CSF was 149 mg/dL. During the follow-up period, 2 patients (6.1%) required VP shunt placement, and no patients experienced complications of ventriculitis or shunt-related infection. CONCLUSION Based on our data, earlier EVD weaning and shunt placement can effectively treat subarachnoid hemorrhage–induced hydrocephalus in patients with severe subarachnoid hemorrhage. This procedure resulted in no shunt-related infections and a 6.1% revision rate. There were fewer adverse effects of IVH and protein on shunt performance. Therefore, weaning from an EVD and conversion to a permanent VP shunt need not be delayed because of IVH or proteinaceous CSF.

The feasibility of lumboperitoneal shunting for hydrocephalus after endovascular coil embolization of aneurysmal subarachnoid hemorrhage

2015 ◽  
Vol 3 (1-2) ◽  
Author(s):  
Hiroaki Neki ◽  
Shinya Kohyama ◽  
Fumitaka Yamane ◽  
Hideaki Ishihara ◽  
Nahoko Uemiya ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Significant Risk ◽  
Symptom Improvement ◽  
Chronic Hydrocephalus ◽  
Improvement Rate ◽  
Vp Shunt ◽  
Shunt Placement ◽  
Imaging Results ◽  
Shunt Group

AbstractWe retrospectively analyzed the clinical usefulness of lumboperitoneal (LP) shunt placement surgery for chronic hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH).A total of 225 patients underwent endovascular coiling for aneurysmal SAH at our institution between April 2007 and May 2012. Of these, the medical records of 190 consecutive patients were retrospectively analyzed for hydrocephalus incidence, shunt procedure-related complication rate, and hydrocephalus improvement rate. Of the 190 cases included for analysis, 102 were classified as Hunt and Hess (H and H) grades 1–2 (low H and H grade) and 88 as grades 3–5 (high H and H grade). Forty-nine cases were classified as Fisher group 1–2 (low Fisher group) and 141 as groups 3–4 (high Fisher group), which included five Fisher group 4 patients.Of the 190 patients analyzed, 22 (11.6%) presented with chronic hydrocephalus and underwent shunt placement surgery. A severe H and H grade (grade 3–5) and high Fisher group (group 3–4) were significant risk factors for chronic hydrocephalus. Twelve LP shunt surgeries and ten ventriculoperitoneal (VP) shunt surgeries were performed. All patients showed symptom improvement as confirmed by imaging results. In the LP shunt group, there were no procedure-related complications. One patient in the VP shunt group developed ventricular hemorrhage and one patient in each group developed a postoperative infection.LP shunting, which is considered relatively less invasive, yielded similar results as VP shunting; therefore, it may be an option for managing chronic hydrocephalus after endovascular treatment for SAH.

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

2018 ◽  
Vol 129 (3) ◽  
pp. 702-710 ◽  
Author(s):  
Yasunori Nagahama ◽  
Lauren Allan ◽  
Daichi Nakagawa ◽  
Mario Zanaty ◽  
Robert M. Starke ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Cerebral Ischemia ◽  
Antiplatelet Therapy ◽  
Dual Antiplatelet Therapy ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
Control Group ◽  
Increased Risk ◽  
Hemorrhagic Complications ◽  
Flow Diverters

OBJECTIVEClinical 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.METHODSAnalysis 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.RESULTSOf 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).CONCLUSIONSThe 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.

Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: incidence, predictors, and revision rates

2009 ◽  
Vol 111 (5) ◽  
pp. 1029-1035 ◽  
Author(s):  
Cian J. O'Kelly ◽  
Abhaya V. Kulkarni ◽  
Peter C. Austin ◽  
David Urbach ◽  
M. Christopher Wallace
Keyword(s):  
Risk Factors ◽  
Multivariate Analysis ◽  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Significant Proportion ◽  
Posterior Circulation ◽  
Administrative Databases ◽  
Ruptured Aneurysm ◽  
Shunt Revision ◽  
Subsequent Revision

Object Chronic shunt-dependent hydrocephalus is a recognized complication of aneurysmal subarachnoid hemorrhage. While its incidence and risk factors have been well described, the long-term performance of shunts in this setting has not been not widely reported. Methods Using administrative databases, the authors derived a retrospective cohort of patients undergoing treatment of a ruptured aneurysm in Ontario, Canada, between 1995 and 2005. The authors determined the incidence of shunt-dependent hydrocephalus and analyzed putative risk factors. Mortality rates and indicators of morbidity were recorded. Patients were followed up for the occurrence of shunt failure over time. Results Of 3120 patients in the cohort, 585 (18.75%) developed shunt-dependent hydrocephalus. On multivariate analysis, age, acute hydrocephalus, ventilation on admission, aneurysms in the posterior circulation and giant aneurysms were all significant predictors of shunt-dependent hydrocephalus. The mortality rate was not increased in patients with chronic hydrocephalus (hazard ratio 1.04, p = 0.63); however, indicators of morbidity were increased in these patients. Of the 585 patients with shunt-dependent hydrocephalus, only 173 (29.6%) underwent a subsequent revision procedure. Ninety-eight percent of these revisions were completed within 6 months. Subsequent revisions occurred more frequently. On multivariate analysis, significant predictors of shunt revision included aneurysm location in the posterior circulation and endovascular treatment of the initial ruptured aneurysm. Conclusions Shunt-dependent hydrocephalus affects a significant proportion of subarachnoid hemorrhage survivors, contributing to additional morbidity among these patients. Shunt failures occur less frequently in patients who underwent treatment for a ruptured aneurysm than with other forms of hydrocephalus. Most failures occur within 6 months, suggesting that shunt dependency may be transient in the majority of patients.

scholarly journals A sustained systemic inflammatory response syndrome is associated with shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage

2019 ◽  
Vol 130 (6) ◽  
pp. 1984-1991 ◽  
Author(s):  
Aaron P. Wessell ◽  
Matthew J. Kole ◽  
Gregory Cannarsa ◽  
Jeffrey Oliver ◽  
Gaurav Jindal ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Subarachnoid Hemorrhage ◽  
Systemic Inflammatory Response Syndrome ◽  
Inflammatory Response ◽  
Regression Model ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Systemic Inflammatory Response ◽  
Multivariate Logistic Regression ◽  
Shunt Placement ◽  
Shunt Dependence

OBJECTIVEThe authors sought to evaluate whether a sustained systemic inflammatory response was associated with shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage.METHODSA retrospective analysis of 193 consecutive patients with aneurysmal subarachnoid hemorrhage was performed. Management of hydrocephalus followed a stepwise algorithm to determine the need for external CSF drainage and subsequent shunt placement. Systemic inflammatory response syndrome (SIRS) data were collected for all patients during the first 7 days of hospitalization. Patients who met the SIRS criteria every day for the first 7 days of hospitalization were considered as having a sustained SIRS. Univariate and multivariate regression analyses were used to determine predictors of shunt dependence.RESULTSSixteen percent of patients required shunt placement. Sustained SIRS was observed in 35% of shunt-dependent patients compared to 14% in non–shunt-dependent patients (p = 0.004). On multivariate logistic regression, female sex (OR 0.35, 95% CI 0.142–0.885), moderate to severe vasospasm (OR 3.78, 95% CI 1.333–10.745), acute hydrocephalus (OR 21.39, 95% CI 2.260–202.417), and sustained SIRS (OR 2.94, 95% CI 1.125–7.689) were significantly associated with shunt dependence after aneurysmal subarachnoid hemorrhage. Receiver operating characteristic analysis revealed an area under the curve of 0.83 for the final regression model.CONCLUSIONSSustained SIRS was a predictor of shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage even after adjustment for potential confounding variables in a multivariate logistic regression model.

Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard

2020 ◽  
Vol 132 (1) ◽  
pp. 79-86 ◽  
Author(s):  
Marvin Darkwah Oppong ◽  
Kathrin Buffen ◽  
Daniela Pierscianek ◽  
Annika Herten ◽  
Yahya Ahmadipour ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Antiplatelet Therapy ◽  
Clinical Data ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Final Analysis ◽  
Minor Bleeding ◽  
Thrombolytic Agents ◽  
Poor Outcome ◽  
Hemorrhagic Complications ◽  
The Impact

OBJECTIVEClinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.METHODSAll consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients’ charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.RESULTSSixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.CONCLUSIONSSHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.

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