The timing of intraprocedural antiplatelet therapy did not affect outcomes in endovascular treatment of ruptured intracranial aneurysms: A systematic review.

BACKGROUND

Thromboembolic complications (TEC) and perforation are known complication sin patients with ruptured intracranial aneurysms treated with primary coiling. Antiplatelet therapy may reduce TEC; however, crucially, there is no direct antidote to reverse the antiplatelet effect if an intraprocedural perforation occurs, which is most likely during first coil deployment. We assessed whether adjunct antithrombotic administration before the procedure or after the first coil offers a better safety-efficacy balance.

MATERIALS AND

METHODS

A PRISMA-based systematic review searched PubMed, Ovid/MEDLINE, and Cochrane CENTRAL to August-2025. Eligible studies reported outcomes of ruptured aneurysm coiling with adjunct antiplatelet drugs, excluding stent-assisted/flow diverter cases. The primary outcome was TEC; secondary outcomes were aneurysm perforation and symptomatic intracranial hemorrhage (sICH). Random-effects meta-analyses used logit transformation; subgroup analyses compared pre-procedural versus post-first coil administration; and leave-one-out sensitivity analyses were performed.

RESULTS

Five studies (n = 526 patients) were included; median Hunt-Hess 2 and Fisher 3. Regimens included aspirin versus no aspirin (3 studies), glycoprotein IIb/IIIa inhibitor versus none (1), and placebo versus clopidogrel versus Dual Antiplatelet Therapy (DAPT) (1).

TIMING: 3 pre-procedural, 2 post-first heterogeneity was modest (I²≈30% across outcomes, however with few studies). Adjunct antiplatelet therapy reduced TEC with similar magnitude whether given before the procedure or after the first coil (pooled OR 3.8 [95% CI 1.2-12.5] pre-procedural vs. 3.4 [0.9-12.2] post-first coil) Rates of perforation and sICH did not differ by timing.

CONCLUSIONS

In ruptured aneurysm coiling, adjunct antiplatelet lower TEC without increasing perforation or sICH, and their efficacy appears comparable when administered after the first coil. Given the absence of an antiplatelet direct antidote, post-first coil administration may offer a pragmatic safety advantage.