Ventriculostomy-Related Hemorrhage After Treatment of Acutely Ruptured Aneurysms: The Influence of Anticoagulation and Antiplatelet Treatment

BACKGROUND: Endovascular techniques have gained importance in recent years in the treatment of acutely ruptured aneurysms. Sometimes artificial anticoagulation or antiplatelet agents are indicated after endovascular aneurysm occlusion to prevent thromboembolic complications. Because many patients require ventriculostomy secondary to hydrocephalus, we analyzed ventriculostomy-related hemorrhage in patients with and without anticoagulant therapy. METHODS: Between January 2007 and December 2013, 444 patients with aneurysmal subarachnoid hemorrhage and acute hydrocephalus received treatment requiring ventriculostomy. Treatment-related complications were entered in a prospectively conducted database and analyzed retrospectively. All patients received low-molecular-weight heparin in prophylactic dosage starting 24 hours after aneurysm treatment. Heparin (dosage depending on patient weight) was administered during all endovascular procedures. RESULTS: In 117 of 444 patients (26%), additional anticoagulation or antiplatelet agents were administered after treatment of the ruptured aneurysm. Heparin was used in 70 of 117 patients (60%), acetylsalicylic acid was used in 61 (52%), clopidogrel was used in 25 (21%), and tirofiban was used in 23 (20%). In 42 patients (36%), anticoagulants and antiplatelet drugs were combined. Ventriculostomy-related hemorrhage was observed in 55 patients (12%). A ventriculostomy-related hemorrhage occurred in 28 of 117 patients (24%) with anticoagulation therapy and in 27 of 327 patients (8%) without anticoagulation therapy (P < 0.001). The hemorrhage rate in all patients receiving endovascular treatment was significantly higher than in patients receiving microsurgical treatment (P < 0.05). Hemorrhage was more likely to be observed when ventriculostomy was performed before the additional anticoagulation was started, although this was not statistically significant. No surgical intervention was necessary to treat ventriculostomy-related bleeding. CONCLUSIONS: Patients receiving endovascular treatment were at higher risk for ventriculostomy-related hemorrhage, especially when anticoagulation was administered after aneurysm occlusion. Although no clinically relevant external ventricular drainerelated hemorrhage occurred, ventriculostomy should be performed before anticoagulation whenever possible.