Antiplatelet Therapy

The use of antiplatelet therapy to prevent DINDs and to improve outcomes after SAH has been motivated by the theoretical advantage of limiting platelet aggregation in an already constricted vessel and the report that some antiplatelet agents might inhibit vasoconstriction mediated through oxyhemoglobin (one of the implicated pathways in vasospasm) (27). In an observational study, it was reported that the RR of cerebral infarct after SAH (as determined by CT scanning) was 0.18 (95% CI 0.04-0.84) in those patients who had been on aspirin before the SAH, compared to those with no history of aspirin use, suggesting a benefit to antiplatelet therapy in the face of SAH (28). Five studies to date have investigated the benefit of anitplatelet therapy in a randomized, controlled design (29-33), and they unanimously report no difference in long-term outcomes in patients treated with antiplatelet agents, as opposed to placebo. Only three trials reported DINDs rates, and only one (31) demonstrated a significant difference between treatment groups. A meta-analysis suggests that the RR of DINDs in patients treated with antiplatelet therapy across trials (RR, 0.65; 95% CI 0.47-0.89) is still significantly less than those not given antiplatelet therapy (34). Unfortunately, for the most part, study samples were prohibitively small (sometimes as small as 11 patients). Accordingly, a more thorough randomized trial is needed to assess the validity and usefulness of antiplatelet therapy in altering outcomes after SAH.

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