gms | German Medical Science

Objective: Intracerebral hemorrhage is a well-recognized complication of antithrombotic therapy. A previous study indicated an increased risk for non-aneurysmal SAH (NASAH) during treatment with systemic anticoagulation or antiplatelet agents (aCP). However, little is known about pathophysiology and management of subarachnoid hemorrhage (SAH) that occurs during treatment with aCP. This study investigated the effect of aCP on blood distribution and outcome in patients with NASAH.

Method: We retrospectively analyzed our institutional database of consecutive patients who suffered from NASAH between 2007 and March 2015. All parameters relevant to this analysis, including hemorrhage pattern on the initial computed tomography (CT) scan done within 24 hours after onset, hospital status, and pretreatment with aCP, were recorded. Also the outcome was compared using the modified Rankin Scale (mRS; favorable outcome mRS 0-2 vs. unfavorable outcome mRS 3-6).

Results: The medical records of 164 patients with NASAH were analyzed, divided into perimesencephalic SAH (PM-SAH) and non-perimesencephalic SAH (NPM-SAH). 117 patients underwent a CT scan within 24 hours after onset, including 51 (44%) with PM-SAH and 66 (56%) with NPM-SAH patients. In total 30 patients (26%) had been pretreated with aCP. The blood distribution was significant altered in patients under aCP, with 73% NPM-SAH compared to 51% (without aCP). Interestingly, the rate of higher Fisher blood distributions increased (Fisher 3 from 20% (without aCP) to 30% (with aCP) and Fisher 4 from 2% to 7%). Patients with aCP had a significant higher risk for NPM-SAH compared to PM-SAH (P<0.05; odds ratio (OR) 2,7) and a trend towards higher bleeding pattern (aCP: Fisher 3/4 in 37% compared to 22% in patients without aCP). Patients treated with aCP had significantly less often a favorable outcome (60% vs. 97% in patients w/o aCP; OR 28). This effect was even stronger in the Fisher 3/4 cohort with only 55% favorable outcome in patients under aCP compared to 100% without aCP (OR 33).

Conclusions: NASAH in patients not pretreated with aCP is associated with an excellent outcome (mRS 0-2 in 98%), whereas pretreated patients had a significantly reduced chance for favorable outcome (60%, OR 28). aCP pretreated patients had a significantly high risk for NPM-SAH. Pretreatment with aCP not only trends towards higher bleeding pattern (Fisher Grade 3/4), but also the risk for unfavorable outcome is additionally (mRS 0-2 only in 55%).