Intervention Review

Antiplatelet therapy for aneurysmal subarachnoid haemorrhage

  1. Sanne Dorhout Mees1,
  2. Walter M van den Bergh1,
  3. Ale Algra2,
  4. Gabriel JE Rinkel1,*

Editorial Group: Cochrane Stroke Group

Published Online: 17 OCT 2007

Assessed as up-to-date: 17 MAY 2007

DOI: 10.1002/14651858.CD006184.pub2

How to Cite

Dorhout Mees S, van den Bergh WM, Algra A, Rinkel GJE. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006184. DOI: 10.1002/14651858.CD006184.pub2.

Author Information

  1. 1

    University Medical Center Utrecht, Department of Neurology, Utrecht, Netherlands

  2. 2

    University Medical Center Utrecht, Julius Centre for Health Sciences and Primary Care, Utrecht, Netherlands

*Gabriel JE Rinkel, Department of Neurology, University Medical Center Utrecht, PO Box 85500, Utrecht, 3508 GA, Netherlands. g.j.e.rinkel@umcutrecht.nl.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 17 OCT 2007

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

Background

Secondary ischaemia is a frequent cause of poor outcome in patients with aneurysmal subarachnoid haemorrhage (SAH). Besides vasospasm, platelet aggregation seems to play a role in the pathogenesis of secondary ischaemia. Experimental studies have suggested that antiplatelet agents can prevent secondary ischaemia.

Objectives

To determine whether antiplatelet agents change outcome in patients with aneurysmal SAH.

Search methods

We searched the Cochrane Stroke Group Trials Register (last searched August 2006), MEDLINE (1966 to August 2006) and EMBASE databases (1980 to August 2006). We also searched reference lists of identified trials.

Selection criteria

All randomised controlled trials (RCTs) comparing any antiplatelet agent with control in patients with aneurysmal SAH.

Data collection and analysis

Two review authors independently extracted the data and assessed trial quality. Relative risks (RR) were calculated with regard to poor outcome, case fatality, secondary ischaemia, haemorrhagic intracranial complications and aneurysmal rebleeding according to the intention-to-treat principle. In case of a statistically significant primary analysis, a worst case analysis was performed.

Main results

Seven RCTs were included in the review, totalling 1385 patients. Four of these trials met the criteria for good quality studies. For any antiplatelet agent there were reductions of a poor outcome (RR 0.79, 95% confidence interval (CI) 0.62 to 1.01) and secondary brain ischaemia (RR 0.79, 95% CI 0.56 to 1.22) and more intracranial haemorrhagic complications (RR 1.36, 95% CI 0.59 to 3.12), but none of these differences were statistically significant. There was no effect on case fatality (RR 1.01, 95% CI 0.74 to 1.37) or aneurysmal rebleeding (RR 0.98, 95% CI 0.78 to 1.38). For individual antiplatelet agents, only ticlopidine was associated with statistically significant fewer occurrences of a poor outcome (RR 0.37, 95% CI 95% CI 0.14 to 0.98) but this estimate was based on only one small RCT.

Authors' conclusions

This review shows a trend towards better outcome in patients treated with antiplatelet agents, possibly due to a reduction in secondary ischaemia. However, results were not statistically significant, thus no definite conclusions can be drawn. Also, antiplatelet agents could increase the risk of haemorrhagic complications. On the basis of the current evidence treatment with antiplatelet agents in order to prevent secondary ischaemia or poor outcome cannot be recommended.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

Antiplatelet therapy for aneurysmal subarachnoid haemorrhage

A subarachnoid haemorrhage (SAH) is a type of stroke due to bleeding in the subarachnoid space, which is the small space between the brain and the skull, and which contains blood vessels that supply the brain. The cause of the bleeding is usually a rupture of a bulge in one of these vessels, which is called an aneurysm. The outcome of patients after SAH is generally poor: 50% of patients die within one month after the haemorrhage, and of those who survive the initial month, 50% remain dependent on someone else for help with activities of daily living (eg, walking, dressing, bathing). One of the causes of poor outcome is a complication of SAH called secondary ischaemia (ischaemia means lack of blood). This complication occurs four to 10 days after the haemorrhage (hence secondary). The cause is not exactly known, but besides contraction of the blood vessels in the brain, there is evidence that clotting of blood platelets plays a role as well. Therefore, trials have been performed with agents that prevent clotting of blood platelets (antiplatelet agents). In this review of seven trials, including 1385 patients, that studied the effects of antiplatelet agents on the outcome after SAH, we found that patients who were treated with antiplatelet agents had a poor outcome less often, and secondary ischaemia less often than patients that received no antiplatelet agent, but the results were not statistically significant and so no definite conclusion can be drawn. Moreover, patients who are treated with antiplatelet agents might have a slightly higher risk of bleeding. Based on these results we conclude that antiplatelet agents after SAH cannot be recommended at the present time.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

动脉瘤性蛛网膜下腔出血的抗血小板治疗

研究背景

动脉瘤性SAH(蛛网膜下腔出血)的患者中,继发性脑缺血是预后不良的常见原因。除血管痉挛外, 血小板聚集也可能是继发性缺血的致病机理。实验研究显示抗血小板药物可以预防继发性脑缺血的发生。

研究目的

明确抗血小板药物能否改善动脉瘤性SAH患者的预后。

检索方法

我们检索了Cochrane Stroke Group Trials Register (截至2006年8月),MEDLINE(1966年–2006年8月)和EMBASE(1980年–2006年8月)等数据库,并追溯纳入试验的参考文献。

纳入标准

纳入所有评价抗血小板药物用于动脉瘤性SAH患者的随机对照试验。

数据收集与分析

两名评价者独立提取数据和评价文献质量。针对不良预后、病例死亡、继发性脑缺血、出血性颅内并发症和动脉瘤再出血等指标,根据意向性分析原则,计算其RR(相对危险度)。若原始研究结果有统计学意义,则采用最坏情况分析。

主要结果

共纳入7个RCT(n=1385),其中4个试验质量较高。结果显示,任何抗血小板药物都可减少不良预后(RR=0.79,95%CI: 0.62~1.01)和继发性脑缺血(RR=0.79,95%CI: 0.56~1.22)的发生,但均增加颅内出血并发症(RR=1.36,95%CI: 0.59~3.12)的发生,但这些差异均无统计学意义。对患者死亡(RR=1.01,95%CI: 0.74~1.37)和动脉瘤再出血(RR=0.98,95%CI: 0.78~1.38)无影响。对于不同的抗血小板药物,只有ticlopidine(噻氯匹啶)减少不良预后的效应有统计学意义(RR=0.37,95%CI: 0.14~0.98),但该结果仅源于一个小样本的RCT。

作者结论

本系统评价发现抗血小板药物治疗有改善预后的可能性,其机理可能是药物减少了继发性脑缺血的发生。然而,由于结果无统计学差异,因此不能得出明确的结论。另外,抗血小板药物可能会增加出血性并发症。基于现有的证据,不推荐使用抗血小板药物预防继发性脑缺血或改善不良预后。

 

概要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

动脉瘤性蛛网膜下腔出血的抗血小板治疗

动脉瘤性蛛网膜下腔出血的抗血小板治疗

SAH(蛛网膜下腔出血)是蛛网膜下腔(大脑和颅骨之间的一个小间隙,内有供应脑部血液的血管)出血引起的一种卒中。出血的原因通常都是这些血管上的动脉瘤破裂所致。SAH患者的预后很差: 50%的患者在出血后的一个月内死亡,而50%存活的患者日常生活(如散步、穿衣、洗澡等)不能自理。继发性脑缺血(SAH的一种并发症)是造成预后不良的原因之一,发生在出血后的4∼10天内。引起继发性脑缺血的原因尚不完全清楚,但除脑血管痉挛外,有证据显示血小板聚集也起到一定作用。因此,已开展了多项抗血小板药物的试验研究。本系统评价纳入7个试验(n=1385),评价了抗血小板药物对SAH的效果。我们发现,相较于对照组,抗血小板药物治疗组的不良预后、继发性缺血等情况均有所减少,但结果均无统计学意义。因此尚不能得出明确的结论。此外,抗血小板药物可能轻微增加出血风险。基于上述结果,我们认为目前不宜推荐使用抗血小板药物治疗SAH。

翻译注解

本摘要由重庆医科大学中国循证卫生保健协作网(China Effective Health Care Network)翻译。

翻译注解":本摘要由重庆医科大学中国循证卫生保健协作网(China Effective Health Care Network)翻译。: China Effective Health Care Network

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要
  5. 概要
  6. 摘要

背景

抗血小板治療動脈瘤性蛛網膜下腔出血

動脈瘤性蛛網膜下腔出血(SAH)的患者中,次發性缺血是不良預後的一種常見原因。此外血管痙攣,血小板聚集似乎在次發性缺血發扮演某種角色。實驗研究顯示抗血小板藥物可以防止次發性缺血。

目標

要確定抗血小板藥物用在動脈瘤性蛛網膜下腔出血患者是否改變結果。

搜尋策略

我們檢索了Cochrane腦中風組試驗註冊資料庫(搜尋至2006年8月),MEDLINE(1966年至2006年8月)和EMBASE資料庫(1980年至2006年8月)。我們還搜尋了所找出試驗的參考資料。

選擇標準

所有在動脈瘤性蛛網膜下腔出血患者比較任何的抗血小板藥物與對照組的隨機對照試驗(RCTs)。

資料收集與分析

兩個文獻回顧作者獨立摘取數據和評估試驗品質。相對危險性(RR)根據不良預後,個案死亡,次發性缺血,併發顱內出血和動脈瘤再出血計算且按照治療意向分析法(intentiontotreat)。在初步分析中統計學上有意義的案例,會依最壞的情況進行分析。

主要結論

7個隨機對照試驗被納入了文獻回顧,共有1385位病人。其中有4個試驗是符合標準的優質研究。對於任一種抗血小板藥物對於不良預後都有降低(相對危險比:0.79,95%可信區間(CI)0.62 – 1.01)和次發性腦缺血(相對危險比:0.79,95%可信區間為0.56至1.22)和更多的顱內出血併發症(相對危險比:1.36, 95%可信區間為0.59 – 3.12),但都沒有統計學上的意義。且在個案死亡率上也沒有影響(相對危險比:1.01,95%可信區間為0.74~1.37)或動脈瘤再出血(相對危險比:0.98,95%可信區間為0.78至1.38)。對於個別的抗血小板藥物,只有ticlopidine有統計學上意義地降低不良預後(相對危險比:0.37,95%可信區間為0.14~0.98),但這一估計只基於一個小的隨機對照試驗。

作者結論

本回顧顯示出在患者接受抗血小板藥物治療會有比較好結果的趨勢,可能是由於減少了次發性缺血。然而,結果並無統計學意義,因此沒有明確的結論可以得出。另外,抗血小板藥物可能會增加出血的併發症。基於現有的證據上,以抗血小板藥物治療以防止次發性缺血或不良預後是不被推薦的。

翻譯人

本摘要由奇美醫院何乘彰翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

抗血小板治療動脈瘤性蛛網膜下腔出血:蛛網膜下腔出血(SAH)是中風的一種類型,因在蛛網膜下腔的空間出血,這是在大腦和頭骨之間的一個小空間,它也包含了供應大腦的血管。出血的原因通常都是這些血管其中的一個突起處(被稱為動脈瘤)破裂所致。蛛網膜下腔出血的病人預後很差:50%的患者在出血後內的一個月死亡,而那些生存過最初第一個月的有50%在日常生活活動(如散步,穿衣,洗澡)要依賴別人的幫助。造成不良預後的其中一個原因是蛛網膜下腔出血的併發症稱為次發性缺血。這種併發症發生在出血後的4至10天,所以稱為次發。其原因不完全清楚,但除了大腦中的血管收縮外,有證據顯示血液中的血小板凝集也扮演了一個角色。因此,防止血小板凝集的物質(抗血小板藥物)的試驗已經被執行。在本回顧中的7個試驗,包含1385位病人,是研究抗血小板藥物用在蛛網膜下腔出血的結果,我們發現在病人接受抗血小板藥物治療的不良預後較少,和次發性缺血也比較少,相較於沒有接受抗血小板藥物者,但結果並不具統計學意義,因此沒有明確的定論。此外,病人接受抗血小板藥物治療可能有較高風險出血。基於這些結果,我們得出結論是目前為止,蛛網膜下腔出血之後不建議使用抗血小板藥物。