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  • Risk of hemorrhagic complication associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on dual antiplatelet therapy.

    Final Number:

    Kelly B. Mahaney MD, MS; Nohra Chalouhi MD; Stephanus V. Viljoen; Janel Smietana MD; David Kung MD; Pascal Jabbour MD; Ketan Ramanlal Bulsara MD; Matthew A. Howard MD; David M. Hasan MD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2013 Annual Meeting

    Introduction: The use of an intracranial stent requires dual antiplatelet therapy to avoid in-stent thrombosis. We investigated whether use of dual antiplatelet therapy is a risk factor for hemorrhagic complications in patients undergoing ventriculoperitoneal shunt for hydrocephalus following aneurysmal subarachnoid hemorrhage (aSAH).

    Methods: Patients were given 325mg acetylsalicylic acid and 600mg clopidogrel during coil/stent procedure and maintained on dual antiplatelet therapy with acetylsalicylic acid 325mg and clopidogrel 75mg daily for 6 weeks post-treatment. Placement of ventriculoperitoneal shunt occurred at a delayed time during initial hospitalization, usually between 7 and 21 days following aSAH. Post-operative computed tomography scans were reviewed for hemorrhages.

    Results: 206 patients were admitted to the University of Iowa Hospitals and Clinics with aSAH between July 2009 and October 2010. Thirty-seven patients were treated with ventriculoperitoneal shunt for persistent hydrocephalus. Twelve patients(32%) had previously undergone stent-assisted coiling and were on dual anti-platelet therapy. The remaining 25(68%) patients had undergone surgical clipping or aneurysm coiling and were not on antiplatelet therapy. Four(10.8%) new intracranial hemorrhages associated with ventriculoperitoneal shunt placement were observed. All four hemorrhages (33%) occurred in patients on dual antiplatelet therapy for stent-assisted coiling, compared to no new intracranial hemorrhages in patients not on dual antiplatelet therapy [4/12(33%) vs. 0/25(0%), p=0.0075]. All four hemorrhages occurred along the ventricular catheter tract. Only one hemorrhage (1/12, 8.3%) was clinically significant, resulting in proximal shunt occlusion requiring revision. The patient did not incur any permanent morbidity related to the hemorrhage.

    Conclusions: This small series suggests placement of ventriculoperitoneal shunt in patients on dual anti-platelet therapy to be associated with an increased, but low rate of symptomatic intracranial hemorrhage. In patients who are poor candidates for open surgical clipping and with aneurysms amenable to stent-assisted coiling, the risk of symptomatic hemorrhage may be an acceptable trade-off for avoiding risks associated with discontinuation of antiplatelet therapy.

    Patient Care: This study will alert Neurosurgeons to the potential hazards of dual antiplatelet therapy in aneurysmal subarachnoid hemorrhage patients requiring treatment of hydrocephalus. The highlighted example of clinically significant hemorrhage should also serve to alert clinicians of small hemorrhage as a potential cause of shunt malfunction. Awareness of such risks can better inform treatment strategies in complex aneurysmal subarachnoid hemorrhage patients, and hopefully result in better patient outcomes.

    Learning Objectives: At the completion of this session, participants should be able to 1) Appreciate the complexity of clinical decision-making in hydrocephalic aneurysmal SAH patients who are treated with stent-assisted coil embolization, 2) Recognize hemorrhage risk during ventriculoperitoneal shunt procedures in patients on dual antiplatelet therapy and incorporate this knowledge into treatment strategies for these complex patients.

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