This Article Full Text (PDF) All Versions of this Article: 39/7/2186    most recent STROKEAHA.107.509257v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Dorhout Mees, S. M. Articles by Rinkel, G. J.E. PubMed PubMed Citation Articles by Dorhout Mees, S. M. Articles by Rinkel, G. J.E. Related Collections Secondary prevention Platelet function inhibitors Antiplatelets

(Stroke. 2008;39:2186.)
© 2008 American Heart Association, Inc.

Cochrane Corner

Antiplatelet Therapy in Aneurysmal Subarachnoid Hemorrhage

Sanne M. Dorhout Mees, MD; Walter M. van den Bergh, MD, PhD; Ale Algra, MD Gabriel J.E. Rinkel, MD

From the Department of Neurology (S.M.D.M., W.M.v.d.B., A.A., G.J.E.R.) and the Julius Center for General Practice and Patient-Oriented Research (A.A.), University Medical Center Utrecht, the Netherlands.

Correspondence to S.M. Dorhout Mees, Room G03.228, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail s.m.dorhoutmees{at}umcutrecht.nl

Graeme J. Hankey MD, FRCP Section Editor:

Key Words: subarachnoid hemorrhage • antiplatelet agents • randomized controlled trials

	Introduction

Top Introduction Methods Main Results Conclusions Reference

 
Secondary ischemia is a frequent cause of poor outcome in patients with aneurysmal subarachnoid hemorrhage (SAH). Besides vasospasm, platelet aggregation seems to play a role in the pathogenesis of secondary ischemia. Experimental studies have suggested that antiplatelet agents can prevent secondary ischemia. The objective of this review was to determine whether antiplatelet agents change outcome in patients with aneurysmal SAH.

	Methods

Top Introduction Methods Main Results Conclusions Reference

 
We searched the Cochrane Stroke Group Trials Register (last searched August 2006), MEDLINE (1966 to August 2006), and EMBASE databases (1980 to August 2006). We also searched reference lists of identified trials. All randomized controlled trials (RCTs) comparing any antiplatelet agent with control in patients with aneurysmal SAH. Two review authors independently extracted the data and assessed trial quality. Relative risks (RR) with corresponding 95% confidence intervals (CIs) were calculated with regard to poor outcome, case fatality, secondary ischemia, hemorrhagic intracranial complications, and aneurysmal rebleeding according to the intention-to-treat principle. In case of a statistically significant primary analysis, a worst case analysis was performed.

	Main Results

Top Introduction Methods Main Results Conclusions Reference

 
Seven RCTs were included in the review, totaling 1385 patients. Four of these trials met predefined criteria for good quality studies. For any antiplatelet agent there were reductions of poor outcome (RR 0.79, 95% CI 0.62 to 1.01; Figure) and secondary brain ischemia (RR 0.79, 95% CI 0.56 to 1.22) and more intracranial hemorrhagic complications (RR 1.36, 95% CI 0.59 to 3.12), but none of these differences were statistically significant. There was no effect on case fatality (RR 1.01, 95% CI 0.74 to 1.37) or aneurysmal rebleeding (RR 0.98, 95% CI 0.78 to 1.38). For individual antiplatelet agents, only ticlopidine was associated with statistically significant fewer occurrences of a poor outcome (RR 0.37, 95% CI 95% CI 0.14 to 0.98), but this estimate was based on only one small RCT.

View larger version (11K): [in this window] [in a new window]   Figure. Poor outcome, according to type of study medication.

	Conclusions

Top Introduction Methods Main Results Conclusions Reference

 
This review shows a trend toward better outcome in patients treated with antiplatelet agents, possibly because of a reduction in secondary ischemia. However, results were not statistically significant, thus no definite conclusions can be drawn. Also, antiplatelet agents could increase the risk of hemorrhagic complications. On the basis of the current evidence, treatment with antiplatelet agents to prevent secondary ischemia or poor outcome cannot be recommended.

Before antiplatelet drugs could be recommended in clinical practice, appropriately powered RCTs are needed. However, it is difficult to make recommendations as to which antiplatelet agent is the most promising agent, as there were no large differences between the antiplatelet drugs. Only ticlopidine showed a statistically significant result, but this drug is not commonly used anymore because of hematologic complications. As there was only one RCT that included patients whose aneurysms were treated by endovascular coiling, it could be worthwhile to perform a new pilot study in patients whose aneurysm are treated by coiling.¹

	Acknowledgments

 
Disclosures

None.

Received November 2, 2007; accepted November 21, 2007.

	Reference

Top Introduction Methods Main Results Conclusions Reference

 

1. Dorhout Mees S, van den Bergh W, Algra A, Rinkel G. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007; 4: CD006184.[Medline] [Order article via Infotrieve]

This Article Full Text (PDF) All Versions of this Article: 39/7/2186    most recent STROKEAHA.107.509257v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Google Scholar Articles by Dorhout Mees, S. M. Articles by Rinkel, G. J.E. PubMed PubMed Citation Articles by Dorhout Mees, S. M. Articles by Rinkel, G. J.E. Related Collections Secondary prevention Platelet function inhibitors Antiplatelets