title: Ventriculostomy-Related Hemorrhage After Treatment of Acutely Ruptured Aneurysms: The Influence of Anticoagulation and Antiplatelet Treatment.
abstract: 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 drain-related hemorrhage occurred, ventriculostomy should be performed before anticoagulation whenever possible.
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany. Electronic address: markus.bruder@kgu.de.
authors.forename: Markus
authors.initials: M
authors.lastname: Bruder
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
authors.forename: Patrick
authors.initials: P
authors.lastname: Schuss
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Konczalla
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
authors.forename: Ahmed
authors.initials: A
authors.lastname: El-Fiki
authors.affiliation: Department of Neuroradiology, Goethe University, Frankfurt am Main, Germany.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Lescher
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
authors.forename: Hartmut
authors.initials: H
authors.lastname: Vatter
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
authors.forename: Volker
authors.initials: V
authors.lastname: Seifert
authors.affiliation: Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
authors.forename: Erdem
authors.initials: E
authors.lastname: Güresir
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000601:surgery*; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects*; D001241:Aspirin / Q000009:adverse effects; D002543:Cerebral Hemorrhage / Q000209:etiology*; D000077144:Clopidogrel; D057510:Endovascular Procedures / Q000009:adverse effects*; D005260:Female; D006495:Heparin, Low-Molecular-Weight / Q000009:adverse effects; D006801:Humans; D006849:Hydrocephalus / Q000601:surgery*; D002532:Intracranial Aneurysm / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage / Q000009:adverse effects*; D012189:Retrospective Studies; D013923:Thromboembolism / Q000209:etiology / Q000517:prevention & control*; D013988:Ticlopidine / Q000009:adverse effects / Q000031:analogs & derivatives; D000077466:Tirofiban; D014443:Tyrosine / Q000009:adverse effects / Q000031:analogs & derivatives; D014696:Ventriculostomy / Q000009:adverse effects*
chemical_list: D000925:Anticoagulants; D006495:Heparin, Low-Molecular-Weight; D010975:Platelet Aggregation Inhibitors; D014443:Tyrosine; D000077144:Clopidogrel; D000077466:Tirofiban; D013988:Ticlopidine; D001241:Aspirin
keywords: Aneurysm; Anticoagulation; Endovascular; Hemorrhage; Subarachnoid hemorrhage; Ventriculostomy