Aneurysmal Subarachnoid Hemorrhage (aSAH), Delayed Cerebral Ischemia
Conditions
Keywords
Aneurysmal subarachnoid hemorrhage, Aspirin, Delayed cerebral ischemia, Antiplatelet therapy, Functional outcome, Randomized controlled trial
Brief summary
This study is a multicenter, prospective, double-blind, randomized controlled trial designed to evaluate whether early prophylactic use of aspirin improves functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). Patients with aSAH who have undergone successful aneurysm securing will be randomly assigned to receive either aspirin plus standard care or a placebo plus standard care. The study drug will be started within 48 hours of undergone successful aneurysm securing and continued for not less than 10 days and not more than 14 consecutive days. The main goal is to compare the rate of favorable functional outcomes at 3 months between the two groups. Secondary goals include evaluating the incidence of delayed cerebral ischemia, cerebral infarction, mortality, and safety outcomes such as major bleeding events.
Detailed description
Aneurysmal subarachnoid hemorrhage (aSAH) is a life-threatening neurological emergency associated with high rates of morbidity and mortality. Delayed cerebral ischemia (DCI) and subsequent cerebral infarction are major contributors to poor functional outcomes in survivors. Antiplatelet agents such as aspirin have been hypothesized to reduce the risk of microthrombosis and DCI, but evidence for their early prophylactic use in aSAH remains limited and controversial. This trial aims to investigate the efficacy and safety of early aspirin administration in improving long-term functional outcomes in aSAH patients. Eligible patients will be randomized into two groups: the intervention group will receive 100 mg of oral aspirin daily for not less than 10 days and not more than 14 consecutive days, while the control group will receive an identical placebo. All patients in both groups will receive standardized aSAH management according to current clinical guidelines, including nimodipine, blood pressure control, and supportive care. The primary endpoint is the functional outcome measured by the modified Rankin Scale (mRS) at 3 months. Secondary endpoints include incidence of clinical DCI at discharge, percentage of imaging DCI detected on CT/MRI at discharge, all-cause mortality at 3 months, and safety outcomes including major bleeding events.
Interventions
DRUGAspirin
Aspirin 100 mg (1 tablet) administered orally, via nasogastric tube, or rectally within 48 hours after aneurysm embolization or surgical clipping, once daily, for a minimum of 10 consecutive days and a maximum of 14 consecutive days.
DRUGPlacebo
Placebo 1 tablet (identical in appearance to aspirin 100 mg) administered orally, via nasogastric tube, or rectally within 48 hours after aneurysm embolization or surgical clipping, once daily, for a minimum of 10 consecutive days and a maximum of 14 consecutive days.
Sponsors
Ganzhou City People's Hospital
The First Affiliated Hospital of Anhui Medical University
First Affiliated Hospital of Wannan Medical College
Nanfang Hospital, Southern Medical University
Second Affiliated Hospital of Guangzhou Medical University
Affiliated Hospital of Guangdong Medical University
Fifth Affiliated Hospital of Guangzhou Medical University
Meizhou People's Hospital
Guizhou Provincial People's Hospital
The First Affiliated Hospital of Nanchang University
Jiangxi Provincial People's Hopital
Huang Shan People's Hospital
Jiu Jiang NO.1 People's Hospital
Ji'an Central People's Hospital
Yichun People's Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
The study drug (aspirin/placebo) is prepared in identical capsules to maintain blinding. All study personnel and participants remain blinded to treatment assignment throughout the trial.
Intervention model description
This is a randomized, double-blind, parallel-group study. Eligible patients with aSAH will be assigned to either the aspirin intervention group or the placebo control group in a 1:1 ratio.
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
1. Age ≥ 18 years and ≤ 80 years. 2. Spontaneous subarachnoid hemorrhage (SAH) confirmed by non-contrast head CT. 3. Diagnosis of ruptured intracranial aneurysm confirmed, and successfully treated by either surgical clipping or endovascular coiling within 48 hours of ictus. 4. Hunt-Hess grade ≤ 4 or WFNS grade ≤ 4 (assessed within 48 hours of SAH onset). 5. Fisher grade 2-4 or modified Fisher grade 1-4. 6. No significant focal neurological deficit after aneurysm intervention, defined as NIHSS scores ≤ 1 in the following items: 5a (left arm motor), 5b (right arm motor), 6a (left leg motor), 6b (right leg motor), and 9 (language). 7. Pre-morbid modified Rankin Scale (mRS) score ≤ 1 prior to SAH onset.
Exclusion criteria
1. Hunt-Hess grade 5 or WFNS grade 5 (assessed within 48 hours of SAH onset). 2. Patients requiring any intracranial stent or non-embolic intrasaccular device during aneurysm embolization, with post-procedural need for antiplatelet therapy. 3. Angiogram-negative SAH. 4. Note: Prior history of ruptured intracranial aneurysm or re-rupture of previously treated aneurysm is not excluded. 5. Moderate-to-severe vasospasm demonstrated on pre-operative or intra-operative CTA/DSA in the emergency setting. 6. SAH caused by non-saccular aneurysms, including mycotic, blood-blister, fusiform, or dissecting aneurysms, or cases without basal cistern subarachnoid hemorrhage. 7. Significant pre-existing intracranial pathology at the time of enrollment, including but not limited to: traumatic brain injury, moyamoya disease, high suspicion or documented CNS vasculitis, severe fibromuscular dysplasia, arteriovenous malformation, arteriovenous fistula, significant cervical or intracranial atherosclerotic stenosis (≥70%), or malignant brain tumor. 8. Medical conditions requiring chronic use of antiplatelet agents (aspirin, clopidogrel, or ticagrelor), such as transient ischemic attack, myocardial infarction, atrial fibrillation, prosthetic heart valve, arteriovenous fistula, unstable angina, or other conditions requiring thromboprophylaxis. 9. Thrombocytopenia (platelet count \<20,000/μL, excluding aggregation artifacts), active disseminated intravascular coagulation (DIC) at enrollment, or documented history of coagulopathy or bleeding diathesis. 10. History of gastrointestinal bleeding or major systemic hemorrhage within 30 days, hemoglobin \<8 g/dL at admission, INR ≥1.5, or severe hepatic impairment defined as AST, ALT, alkaline phosphatase (AP), or GGT \>2 times the upper limit of normal. 11. Creatinine clearance \<30 mL/min. 12. Severe comorbidities that may confound study outcomes, including but not limited to: multiple sclerosis, dementia, major depression, immunosuppressed state or during intensive immunosuppressive therapy, cancer with expected survival \<1 year, multi-organ failure, or any other condition potentially causing cognitive impairment. 13. Contraindications to aspirin therapy, including: * Hypersensitivity to aspirin, other salicylates, or any excipients in the formulation; * History of asthma induced by salicylates or NSAIDs; * Active peptic ulcer disease; * Bleeding diathesis; * Hepatic or renal failure; * Uncontrolled severe heart failure; * Concomitant use with methotrexate at doses ≥15 mg/week. 14. Pregnancy or positive HCG test. 15. Incomplete repair of the responsible aneurysm as judged by the treating physician, with high risk of early re-bleeding. 16. History of head trauma within 3 months prior to SAH onset. 17. Recent cerebral disease within 3 months prior to SAH onset, such as tumor, stroke, epilepsy, vasculitis, AVM, or hydrocephalus. 18. History of psychiatric illness or seizure disorder. 19. Breastfeeding women. 20. Expected survival \<1 year prior to SAH onset. 21. Participation in another randomized clinical trial that may confound the evaluation of this study.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Proportion of patients with mRS 0-2 at 90 days after randomization | 90 days after randomization | The proportion of patients with modified Rankin Scale (mRS) scores ranging from 0 to 2 at 90 days after randomization. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Extended Glasgow Outcome Scale (eGOS) at 90 days | 90 days after randomization | Functional prognosis assessed by Extended Glasgow Outcome Scale (eGOS) at 90 days after randomization. |
| Ordinal shift analysis of mRS at 90 days (mRS 5 and 6 combined) | 90 days after randomization | Ordinal shift analysis of modified Rankin Scale scores at 90 days after randomization, with mRS grade 5 and 6 merged into one category. |
| Proportion of patients with mRS 0-3 at 90 days | 90 days after randomization | Proportion of patients with modified Rankin Scale scores of 0 to 3 at 90 days after randomization. |
| Mini-Mental State Examination (MMSE) score at 90 days | 90 days after randomization | Cognitive function assessed via Mini-Mental State Examination (MMSE) scale. |
| Extended Glasgow Outcome Scale (eGOS) at 1 year | 1 year after randomization. | Functional outcome assessed by Extended Glasgow Outcome Scale at 1 year after randomization. |
| Ordinal shift analysis of mRS at 1 year (mRS 5 and 6 combined) | 1 year after randomization | Ordinal shift analysis of modified Rankin Scale scores at 1 year after randomization, combining mRS 5 and mRS 6 into a single category. |
| Proportion of mRS 0-2 at 1 year | 1 year after randomization. | Proportion of patients with modified Rankin Scale scores of 0 to 2 at 1 year after randomization. |
| Proportion of patients with mRS 0-3 at 1 year | 1 year after randomization. | Percentage of subjects achieving modified Rankin Scale scores from 0 to 3 at one year after randomization. |
| Mini-Mental State Examination (MMSE) score at 1 year | 1 year after randomization | Cognitive function evaluated by Mini-Mental State Examination (MMSE) scale. |
| Change in NIHSS score from baseline at discharge | 30 days/discharge, which ever is earlier | Changes in National Institutes of Health Stroke Scale (NIHSS) scores at discharge compared with baseline levels. |
| Incidence of clinical delayed cerebral ischemia at discharge | 30 days/discharge, which ever is earlier | Incidence rate of clinical delayed cerebral ischemia (DCI) observed at hospital discharge. |
| Percentage of radiological DCI on CT/MRI at discharge | 30 days/discharge, which ever is earlier | Proportion of patients with radiological delayed cerebral ischemia confirmed by cranial CT or MRI at hospital discharge. |
| Lesion volume of radiological DCI on CT/MRI at discharge | 30 days/discharge, which ever is earlier | Volume of lesions consistent with radiological delayed cerebral ischemia detected by cranial CT or MRI at hospital discharge. |
| Incidence of invasive interventions | 30 days/discharge, which ever is earlier | Incidence of invasive interventions including DSA and angioplasty performed during hospitalization. |
| Rate of cerebrospinal fluid shunt surgery within 3 months | Within 3 months after randomization | Proportion of patients receiving cerebrospinal fluid shunt surgery within 3 months after randomization. |
Countries
China
Contacts
CONTACTWeilong Huang, MD. PhD.
CONTACTZhenyu zhang, MD. PhD.
PRINCIPAL_INVESTIGATORQiuHua Jiang, MD. PhD.
Ganzhou People's Hospital, Ganzhou, Jiangxi Province, China
PRINCIPAL_INVESTIGATORZeguang Ren, MD. PhD.
Houston Methodist, Houston, USA
Outcome results
None listed