Elsevier

World Neurosurgery

Volume 113, May 2018, Pages e122-e128
World Neurosurgery

Original Article
Continuous Acetylsalicylic Acid Treatment Does Not Influence Bleeding Pattern or Outcome of Aneurysmal Subarachnoid Hemorrhage: A Matched-Pair Analysis

Parts of this article were presented at the annual meeting of the German Neurosurgical Society on May 15, 2016, in Frankfurt Germany as an oral presentation within a plenary session.
https://doi.org/10.1016/j.wneu.2018.01.188Get rights and content

Highlights

  • Matched-pair analysis comparing patients with and without continuous ASA use at the time of aneurysm rupture.

  • The number of patients with ASA use is significantly rising in the last years.

  • Complication rates or outcome does not differ comparing patients with and without ASA.

  • There was no difference in endovascular or microsurgical treated patients with ASA use.

  • Treatment decision should not be influenced by preexisting ASA medication.

Objective

Demographic changes are leading to an aging society with a growing number of patients with cardiovascular diseases, relying on antiplatelet drugs like acetylsalicylic acid (ASA). Although antiplatelet agents are suspected to be protective not only in the cardiologic but in the neurovascular field, the alteration of the coagulating process could have a major impact on the course and outcome after rupture of intracranial aneurysms.

Methods

Between June 1999 and December 2014, 1422 patients were treated for aneurysmal SAH in our institution, 144 (10.1%) with continuous ASA at the time of aneurysm rupture. A matched-pair analysis was performed.

Results

The rate of patients with continuous ASA treatment while rupture of the aneurysm is rising significantly (P < 0.01). Those patients were significantly older than patients without ASA (60 vs. 53 years, P < 0.001). ASA-treated patients more often had aneurysmal rebleeding (4.7% vs. 2.3%, P = 0.3) and treatment-related hemorrhagic complications (13.9% vs. 6.2%, P = 0.06). However, rates were not different in microsurgical or endovascular procedures (16.4% vs. 12.2%, P = 0.6). Favorable outcome (Modified Rankin Scale 0–2) was achieved in 49.3% of the ASA group and 52.1% of the control group (P = 0.7).

Conclusion

Patients with continuous ASA treatment were significantly older than patients without ASA, but there was no difference in admission status or bleeding pattern. Outcome was not different in the matched-pair analysis. There was no statistical difference in treatment related-complication rates of microsurgical and endovascular procedures. Therefore, ASA use should not influence treatment decision of the ruptured aneurysm.

Introduction

Demographic changes are leading to an aging society with a growing number of patients with cardiovascular diseases, treated with antiplatelet drugs like acetylsalicylic acid (ASA).1, 2 Therefore, the number of patients experiencing subarachnoid hemorrhage (SAH) during treatment with these drugs is rising.3, 4 ASA has been suspected to prevent aneurysm formation or rupture or to reduce secondary brain injury.5, 6, 7, 8 An analysis of the International Study of Unruptured Intracranial Aneurysms cohort revealed an decreased risk for SAH in patients with an unruptured aneurysm when ASA was regularly used.6 However, there are some reports of patients experiencing SAH during treatment with ASA. The outcome in those patients varies in the literature but is more often described to be unfavorable.4, 9 Patients with ASA use are older and are more often treated endovascularly.9 Given that these variables are predictive parameters for outcome in SAH patients, we performed a matched-pair analysis to compensate for them and to analyze the characteristics, treatment course, and outcome in patients with continuous ASA use at the time of rupture of an intracranial aneurysm.

Section snippets

Materials and Methods

Between June 1999 and December 2014, 1422 patients were treated for aneurysmal SAH in our clinic. SAH was proven by cranial computed tomography (CT) or lumbar puncture. We included only patients in whom cerebral angiography revealed intracranial aneurysm as the bleeding source. Information including patient characteristics, existing medication, treatment modality, and radiologic findings were prospectively obtained in a computerized database (IBM SPSS Statistics, Version 22, Armonk, NY). This

Results

Of the total of 1422 patients, 144 (10.1%) were receiving continuous ASA treatment at the time of aneurysm rupture. The rate of patients with ASA treatment continuously and significantly rose from 7.6% in the period 1999 to 2002 up to 16.2% in the period 2012 to 2014 (P < 0.01) (Figure 1). Patient characteristics, admission status, and treatment modalities are given in Table 1.

Admission status based on the Hunt and Hess criteria and the WFNS score did not differ; also, the rate of Fisher 3

Discussion

With aging of the society, the numbers of patients taking antiplatelet medication are rising as the number of cardiovascular and neurovascular diseases increases with age.1, 2 Even though more advanced pharmaceutical agents are conquering the market, ASA is still one of the most often used antiplatelet agents. The rate of patients in our institution with continuous ASA treatment at the time of aneurysm rupture increased significantly over the observed period of this survey up to more than 16% (

Conclusion

The number of patients with from SAH and receiving continuous ASA treatment at the time of aneurysm rupture has significantly risen over the past years. Those patients are significantly older than patients without ASA, but there is no difference in neurologic status or bleeding pattern at the time of admission. In the matched-pair control analysis, outcome or rate of cerebral infarctions did not differ as well. Even though hemorrhagic complications and rebleeding until aneurysm repair seemed to

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    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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