Snyder M Harrison, Ironside Natasha, Kumar Jeyan S, Doan Kevin T, Kellogg Ryan T, Provencio J Javier, Starke Robert M, Park Min S, Ding Dale, Chen Ching-Jen
1Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts.
2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia.
J Neurosurg. 2021 Nov 5;137(1):95-107. doi: 10.3171/2021.7.JNS211239. Print 2022 Jul 1.
Delayed cerebral ischemia (DCI) is a potentially preventable cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The authors performed a meta-analysis to assess the effect of antiplatelet therapy (APT) on DCI in patients with aSAH.
A systematic review of the PubMed and MEDLINE databases was performed. Study inclusion criteria were 1) ≥ 5 aSAH patients; 2) direct comparison between aSAH management with APT and without APT; and 3) reporting of DCI, angiographic, or symptomatic vasospasm rates for patients treated with versus without APT. The primary efficacy outcome was DCI. The outcomes of the APT versus no-APT cohorts were compared. Bias was assessed using the Downs and Black checklist.
The overall cohort comprised 2039 patients from 15 studies. DCI occurred less commonly in the APT compared with the no-APT cohort (pooled = 15.9% vs 28.6%; OR 0.47, p < 0.01). Angiographic (pooled = 51.6% vs 68.7%; OR 0.46, p < 0.01) and symptomatic (pooled = 23.6% vs 37.7%; OR 0.51, p = 0.01) vasospasm rates were lower in the APT cohort. In-hospital mortality (pooled = 1.7% vs 4.1%; OR 0.53, p = 0.01) and functional dependence (pooled = 21.0% vs 35.7%; OR 0.53, p < 0.01) rates were also lower in the APT cohort. Bleeding event rates were comparable between the two cohorts. Subgroup analysis of cilostazol monotherapy compared with no APT demonstrated a lower DCI rate in the cilostazol cohort (pooled = 10.6% vs 28.1%; OR 0.31, p < 0.01). Subgroup analysis of surgically treated aneurysms demonstrated a lower DCI rate for the APT cohort (pooled = 18.4% vs 33.9%; OR 0.43, p = 0.02).
APT is associated with improved outcomes in aSAH without an increased risk of bleeding events, particularly in patients who underwent surgical aneurysm repair and those treated with cilostazol. Although study heterogeneity is the most significant limitation of the analysis, the findings suggest that APT is worth exploring in patients with aSAH, particularly in a randomized controlled trial setting.
迟发性脑缺血（DCI）是动脉瘤性蛛网膜下腔出血（aSAH）后潜在可预防的发病和死亡原因。作者进行了一项荟萃分析，以评估抗血小板治疗（APT）对aSAH患者DCI的影响。
对PubMed和MEDLINE数据库进行系统评价。研究纳入标准为：1）≥5例aSAH患者；2）接受APT与未接受APT的aSAH治疗的直接比较；3）报告接受与未接受APT治疗患者的DCI、血管造影或症状性血管痉挛发生率。主要疗效指标为DCI。比较了APT组与非APT组的结果。使用唐斯和布莱克检查表评估偏倚。
整个队列包括来自15项研究的2039例患者。与非APT组相比，APT组DCI的发生频率较低（合并发生率=15.9%对28.6%；OR 0.47，p<0.01）。APT组的血管造影（合并发生率=51.6%对68.7%；OR 0.46，p<0.01）和症状性（合并发生率=23.6%对37.7%；OR 0.51，p=0.01）血管痉挛发生率较低。APT组的住院死亡率（合并发生率=1.7%对4.1%；OR 0.53，p=0.01）和功能依赖率（合并发生率=21.0%对35.7%；OR 0.53，p<0.01）也较低。两组的出血事件发生率相当。西洛他唑单药治疗与未接受APT治疗的亚组分析显示，西洛他唑组的DCI发生率较低（合并发生率=10.6%对28.1%；OR 0.31，p<0.01）。手术治疗动脉瘤的亚组分析显示，APT组的DCI发生率较低（合并发生率=18.4%对33.9%；OR 0.43，p=0.02）。
APT与aSAH患者预后改善相关，且不增加出血事件风险，尤其是在接受手术动脉瘤修复的患者和接受西洛他唑治疗的患者中。尽管研究异质性是分析的最显著局限性，但研究结果表明，APT在aSAH患者中值得探索，尤其是在随机对照试验环境中。
