To use or not to use antithrombotics in unruptured cerebrovascular malformations? A systematic review focusing on this clinical and surgical dilemma
Author:
Bianconi Andrea1, Ceraudo Marco2, Nico Elsa3, Minardi Massimiliano1, Allevi Mario1, Prior Alessandro2, Garbossa Diego1, Zona Gianluigi24, Fiaschi Pietro24
Affiliation:
1. Department of Neuroscience, Section of Neurosurgery, AOU Città della Salute e della Scienza, University of Turin, Italy; 2. Neurosurgery, IRCCS Policlinico San Martino, Genova, Italy; 3. Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and 4. Section of Neurosurgery, Department of Neuroscienze, Riabilitazione, Section of Neurosurgery, Oftalmologia, Genetica e Scienze Materno-Infantili, University of Genova, Italy
Abstract
OBJECTIVE
Antithrombotic medications (ATMs), including antiplatelet therapy (APT) and oral anticoagulants (OACs), are widely used in current clinical practice for the prevention and treatment of a variety of cardiovascular diseases, deep vein thrombosis, and pulmonary thromboembolisms. The long-term usage of these drugs, associated with an inherent risk of bleeding, raises concerns for unruptured cerebrovascular malformations (UCVMs), such as arteriovenous malformations (AVMs), cerebral cavernous malformations (CCMs), and intracranial aneurysms (IAs), in which the bleeding risk also poses a major threat. The aim of this study was to assess the safety and risk-benefit ratio of ATMs in these various neurosurgical diseases and to give neurosurgeons a safe and reasonable choice regarding whether to administer ATMs to these patients during the course of the disease.
METHODS
The authors conducted a systematic review of the literature (PubMed/MEDLINE and Embase) according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines, which yielded 4 papers about CCMs, 2 about AVMs, and 9 about IAs. The risk of bias was assessed using the Cochrane Collaboration’s tool.
RESULTS
For AVMs, only 2 studies with a total of only 14 patients were included. Data on AVMs and ATMs are limited and weak, relying on small case series. Nevertheless, there is no evidence for either an increased risk of intracranial hemorrhage in patients with AVMs who are receiving ATMS or the need to interrupt ATMs in those patients who have been diagnosed with sporadic, unruptured brain AVMs. With respect to CCMs, the literature search resulted in 4 cohort studies and 1 meta-analysis. These studies affirmed the absence of a correlation between ATMs and an increased risk of CCM bleeding while simultaneously suggesting a protective role of ATMs against bleeding. Concerning IAs, the topic is more complex and debated, despite larger case series on IAs than on AVMs or CCMs. The benefits of ATMs for IAs may vary according to the type of intervention and specific drug administered. Evidence supports the continuation of long-term APT for all patients newly diagnosed with an IA, whereas starting APT in patients with incidentally discovered IA as a means of prophylaxis against rupture is unclear.
CONCLUSIONS
The findings of this review should be taken as a wide overview of UCVM and ATM. Future research should consider the relationship of AVM, CCM, and IA with APT and OAC independently.
Publisher
Journal of Neurosurgery Publishing Group (JNSPG)
Subject
Neurology (clinical),General Medicine,Surgery
Reference44 articles.
1. Clinical practice for antiplatelet and anticoagulant therapy in neurosurgery: data from an Italian survey and summary of current recommendations—part I, antiplatelet therapy;Fiaschi P,2021 2. How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH);Prior A,2021 3. Anticoagulant therapy in high grade gliomas: a systematic review on state of the art and future perspectives;Bianconi A,2023 4. Meta-analysis of reversal agents for severe bleeding associated with direct oral anticoagulants;Gómez-Outes A,2021 5. Risk of intracranial hemorrhage with direct oral anticoagulants: a systematic review and meta-analysis of randomized controlled trials;Wu T,2022
Cited by
1 articles.
订阅此论文施引文献
订阅此论文施引文献,注册后可以免费订阅5篇论文的施引文献,订阅后可以查看论文全部施引文献
|
|