20 June 2026 : Review article
Indications for Dual Antiplatelet Therapy in Coil-Only Treatment of Ruptured Intracranial Aneurysms: A Narrative Review
Mariusz Sowa
ACDEFG 1, Joanna Sowa E 2*
DOI: 10.12659/MSM.952805
Med Sci Monit 2026; 32:e952805
Table 1 Summary of published antiplatelet therapy protocols.
| Author | Heparin administration | Preoperative | Intraoperative | Postoperative | Key findings |
|---|---|---|---|---|---|
| Ries et al []11 | 2000–3000 IU IV infusion before guiding catheter insertion | – | 250 mg ASA after first coil | – | Thromboembolic events during procedure were more frequent in non-ASA group than in ASA group (14/159 aneurysms, 8.8%; =0.028; Fisher’s exact test) |
| Edwards et al []10 | IV bolus of 70–100 IU/kg 5 min before embolization, continuous infusion to ACT 250–300 s | – | 650 mg ASA at end of procedure | 325 mg ASA daily for 14 days | Aspirin administration in high-risk patients significantly decreased periprocedural TEEs, from 53.8% in control group to 10.6% in aspirin-treated group (=0.001). No major systemic hemorrhagic complications were observed; aspirin did not increase risks of aneurysm rebleeding, symptomatic intracranial hemorrhage, or major EVD-associated hemorrhage (=0.3). Asymptomatic minor (<1 cm) EVD-associated hemorrhage was more frequent in aspirin-treated group (=0.02) |
| Ditz et al []20 | Post-treatment anticoagulation from day 1 | – | – | 100 mg ASA daily for 4–12 weeks | Antiplatelet therapy was independently associated with lower incidence of unfavorable functional outcome (OR 0.40 [95% CI: 0.19–0.87], =0.021) at 3 months. Antiplatelet therapy did not reduce incidences of angiographic CVS or DCI-related infarction |
| Evans et al []14 | Procedure performed under systemic heparinization | – | 300–1000 mg ASA (typically 500 mg) at procedure start | 75 mg ASA daily | Ventriculostomy-associated hemorrhage rate was significantly higher in patients receiving intravenous aspirin (30% vs 2.5%; OR 16.7 [95% CI: 2.2–128.0], <0.0001). No hematoma required surgical evacuation. No difference in favorable outcome at discharge or mortality was observed between groups |
| Shimamura et al []13 | Continuous infusion to ACT 200 s during procedure | 200 mg ASA or 200 mg ASA and 150–300 mg clopidogrel | – | 200 mg cilostazol daily for 14 days and 100 mg ASA daily from day 15 onward | TEEs decreased with increasing numbers of antiplatelet agents. No hemorrhagic complications attributable to antiplatelet therapy were observed. Postoperative symptomatic CVS tended to decrease, and outcomes tended to improve, in groups receiving multiple medications. Reduced TEEs were significantly associated with improved clinical outcomes in logistic regression analysis |
| Muraoka et al []12 | Continuous infusion to ACT 200–250 s during procedure | 100 mg ASA and 200 mg clopidogrel | – | – | Incidence of TEEs was slightly lower in clopidogrel loading-dose group than in no-administration group (=0.4). Incidence of TEEs was significantly lower in dual loading-dose group than in no-administration group (=0.0396) |
| Hirai et al []23 | Continuous infusion to ACT 250–300 s during procedure | 200 mg ASA | – | – | Study protocol only; no clinical outcome data are currently available |
| ACT – activated clotting time; ASA – acetylsalicylic acid; CI – confidence interval; CVS – cerebral vasospasm; DCI – delayed cerebral ischemia; EVD – external ventricular drain; IV – intravenous; OR – odds ratio; TEEs – thromboembolic events | |||||