Object: Stenting and flow diversion of ruptured intracranial aneurysms requires the use of dual antiplatelet therapy (DAPT). These patients may be at increased risk for post surgical hemorrhagic complication. In this study, we sought to investigate whether DAPT is a risk factor for hemorrhagic complication associated with placement of external ventricular drains (EVD) in patients with aneurysmal sub-arachnoid hemorrhage (aSAH).
Methods: Patients at our institution with aSAH requiring placement of an EVD for obstructive hydrocephalus between July of 2009 and November of 2016 were included. Rates of radiographically identified hemorrhage associated with EVD placement were compared between patients who were on DAPT for use of a stent or flow diverter, and patients who underwent microsurgical clipping or coiling and were not on DAPT by way of a backward stepwise multivariate analysis. Hemorrhages were judged to be clinically significant if they were temporally associated with neurologic declines, required surgical intervention, or caused seizures.
Results: 443 patients were admitted for management of aSAH. 298 Required placement of an EVD. 120 (40%) were treated with stent assisted coiling or flow diverters and required DAPT, while 178 (60%) were treated with coiling without stents or microsurgical clipping and were not on DAPT. 42 (14%) cases of new hemorrhage along the EVD catheter were identified radiographically. 32 of these hemorrhages occurred in patients on DAPT, while while 10 occurred in patients not on DAPT. After multivariate analysis, DAPT was significantly associated with radiographic hemorrhage [OR: 4.92, 95% CI: 2.45-9.91, p=.0001]. 5 hemorrhages (5 of 10 [50%]) were classified as symptomatic in those patients not receiving DAPT, while 10 hemorrhages (10 of 32 [31%]) were classified as symptomatic in those patients on DAPT (p=.4508).
Conclusions: Our series confirms that patients with aSAH who receive stent assisted coiling or flow diversion are at higher risk for radiographic hemorrhage associated with EVD placement. This increased hemorrhage risk does not appear to be clinically significant. These data suggest that stent assisted coiling and flow diversion for aSAH are viable options in an era of evolving endovascular therapeutics.