Management of Prehemorrhage Antiplatelet Use in Aneurysmal Subarachnoid Hemorrhage: An International Survey of Current Practice

Aims: Aneurysmal subarachnoid hemorrhage (aSAH) comprises only 5% of all strokes but is an important subtype due to the high morbidity and mortality in the relatively young population. The case fatality in aSAH is 50% due to the initial hemorrhage or subsequent complications like recurrent aneurysmal hemorrhage (rebleed) or delayed cerebral ischemia (DCI). One factor that might influence the initial brain damage of subsequent complications is the use of antiplatelet medication before the initial hemorrhage. Studies that have investigated outcome with antiplatelet use before aSAH show conflicting results and literature regarding aSAH patients who used antiplatelet agents before aneurysmal rupture is scarce. The management of these patients, therefore, remains an issue of debate, because evidence is lacking. Our goal was to assess the management of prehemorrhage use of antiplatelet agents in aSAH patients in an international panel of physicians.

Methods: We developed a survey of 11 questions about the management of aSAH patients with antiplatelet use before the initial hemorrhage. A paper version of this survey was distributed to the attendees of the annual meeting of the European Association of Neurosurgical Societies, which took place in Venice, Italy at 1 to 5 October 2017.

Results: Of the 478 surveys we distributed, we received 258 (54%) completed surveys. In ~80%, the departments of neurosurgery and neurology were responsible for acute management of aSAH patients. Department guidelines regarding management of prehemorrhage antiplatelet use in aSAH patients were present in 32%. Approximately two-thirds (65%) of all responders always stop the administration of antiplatelet agents at admission and only 4.3% always transfuse thrombocytes. When a guideline is present, the physicians tend to stop the antiplatelet medication more often and thrombocytes are transfused more often (p = 0.056 and p = 0.02, respectively).

Conclusion: Our survey showed that there is a significant variability in the management of aSAH patients who have been using antiplatelets before the hemorrhage. The presence of a hospital guideline appears to influence the decision of stopping the antiplatelet agent or to transfuse platelets. These findings emphasize the importance of randomized clinical trials for patients with aSAH and prehemorrhage use of antiplatelets.