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Published on: June 18, 2021
Antiplatelet therapy and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and
M Harrison Snyder1, Natasha Ironside2, Jeyan S Kumar2
11Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts.
Insights
Antiplatelet therapy (APT) significantly reduces delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). This meta-analysis found APT improved outcomes without increasing bleeding risks, suggesting its potential benefit in aSAH management.
Area of Science:
- Neurology
- Neurosurgery
- Pharmacology
Background:
- Delayed cerebral ischemia (DCI) is a major complication following aneurysmal subarachnoid hemorrhage (aSAH), contributing to significant morbidity and mortality.
- Effective preventative strategies for DCI are crucial for improving patient outcomes after aSAH.
Purpose of the Study:
- To conduct a meta-analysis evaluating the impact of antiplatelet therapy (APT) on the incidence of DCI in patients with aSAH.
- To assess the safety and efficacy of APT in managing aSAH, focusing on DCI, vasospasm, mortality, and bleeding events.
Main Methods:
- Systematic review of PubMed and MEDLINE databases for studies comparing APT with no APT in aSAH patients.
- Inclusion criteria: ≥ 5 aSAH patients, direct comparison of APT vs. no APT, reporting of DCI, angiographic, or symptomatic vasospasm rates.
- Primary outcome: DCI. Secondary outcomes included vasospasm, mortality, functional dependence, and bleeding events. Bias assessed using Downs and Black checklist.
Main Results:
- The meta-analysis included 2039 patients from 15 studies.
- APT was associated with significantly lower rates of DCI (15.9% vs. 28.6%), angiographic vasospasm (51.6% vs. 68.7%), symptomatic vasospasm (23.6% vs. 37.7%), in-hospital mortality (1.7% vs. 4.1%), and functional dependence (21.0% vs. 35.7%).
- Bleeding event rates were comparable between APT and no-APT cohorts. Subgroup analyses showed reduced DCI with cilostazol monotherapy and in surgically treated aneurysms with APT.
Conclusions:
- Antiplatelet therapy (APT) demonstrates a significant benefit in reducing DCI and improving outcomes in aSAH patients without increasing bleeding risk.
- Particular benefits were observed in patients undergoing surgical aneurysm repair and those treated with cilostazol.
- Findings support further investigation of APT in aSAH, ideally through randomized controlled trials, despite study heterogeneity.
Objective:
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.
Methods:
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.
Results:
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).
Conclusions:
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.
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