Platelet transfusion and antiplatelet timing not associated with decreased rates of ventriculostomy hemorrhage in aneurysmal subarachnoid hemorrhage

Introduction

The increasing use of single (SAPT) and dual antiplatelet therapy (DAPT) in endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH) raises concerns about ventriculostomy-related hemorrhage (VRH). This study evaluates the impact of platelet transfusion, timing of ventriculostomy placement relative to antiplatelet therapy (APT), and APT type (DAPT vs. SAPT) on VRH risk and clinical outcomes.

Methods

A retrospective study of a prospectively collected cohort of aSAH presenting to a single academic center from 2016 to 2023 was conducted. Patients who underwent ventriculostomy placement and APT were included, while those on anticoagulation were excluded. The cohort was then split into three groups: 1) patients on APT at the time of ventriculostomy placement and who were not given platelet transfusion, 2) patients on APT at the time of ventriculostomy placement and who were given platelet transfusion, and 3) patients who were initiated on APT after ventriculostomy placement as part of their endovascular therapy. Univariate and multivariate analyses were performed examining rates of tract hemorrhage, symptomatic tract hemorrhage, and poor neurologic outcomes at three-months, defined as modified Rankin scale (mRS) > 3.

Results

Among 404 cases identified, 129 patients were on APT during or after ventriculostomy placement. Mean age was 59.5 ± 13.9 years, 38.8 % male, and 74.4 % were White. When comparing those who were on APT and did not receive platelet transfusion (n = 24) with those who received platelet transfusion (n = 34), there were no differences in rates of VRH or symptomatic VRH on univariate (37.5 % vs. 29.4 %, p = 0.52 and 4.2 % vs. 5.9 %, p = 0.77, respectively) or multivariate analysis (OR 0.79, 95 %CI [0.24, 2.61], p = 0.7 and OR 0.28, 95 %CI [0.01, 7.99], p = 0.4. Comparing those already on APT versus those with APT initiation after ventriculostomy, there were no statistically significant differences in rates of VRH or symptomatic VRH on univariate (37.5 % vs. 25.4 %, p = 0.26 and 4.2 % vs. 1.4 %, p = 0.42, respectively) or multivariate analysis (OR 0.74, 95 %CI [0.42, 1.31], p = 0.3 and OR 0.28, 95 %CI [0.01, 7.99], p = 0.4). Furthermore, there were no differences in functional neurologic outcomes at 3-month follow-up on multivariate analysis.

Conclusion

Our study did not identify benefits conferred from platelet transfusion with regard to VRH or outcomes after ventriculostomy placement in aSAH on APT. We also found no differences in VRH in patients who had ventriculostomy placement before or after APT initiation. With the increasing use of endovascular therapies, ventriculostomy placement under APT is increasingly common, necessitating further research to mitigate the risk of significant VRH.