A Single Centre Study Of Cognitive Outcomes In Patients With Ruptured Intracranial Aneurysms Receiving Low Dose Heparin Infusion Post Endovascular Coiling.

Abstract

Introduction: Aneurysmal sub arachnoid haemorrhage (aSAH)  carries the highest risk of mortality among haemorrhagic stroke patients. Aneurysmal SAHs have significant impact on cognition where half of the survivors have severe neurological and cognitive deficits. Majority of these morbidity is due to early brain injury (EBI) and delayed cerebral ischemia (DCI) as a consequence of inflammation following aSAH. Low dose Heparin infusion has been used as an anti-inflammatory agent as well  as to improve rheology on these DCI patients(Maryland Protocol). We introduced the protocol in our institution in January of 2018 and have carried out a retrospective quasi experimental study to compare cognitive outcomes before and after introduction of the protocol. Methods: A retrospective quasi experimental analysis of patients with aSAH treated with endovascular coiling between Jan 2015 and Dec 2017 (No Heparin group -Group 1) and Jan 2018 to December 2021 (Heparin group - Group2 ) was done. The protocol was administered to all patients who arrived within 96hrs post ictus in whom the aneurysm had been secured by endovascular coiling. Group2 received a heparin infusion at 10U/Kg/hr started 6 hours after coiling of the aneurysm and maintained for up to day 14 post-ictus. A Montreal cognitive assessment score (MOCA) and the mRS was then conducted in all patients at 6months by a trained health care giver and analysed. Results: 36 patients were assessed in Group11 vs 33 in  Group2.There was a significant improvement in the Mean MoCA Scores 23.5 vs 27 in Group 1 vs 2, p= .0032.The was tendency to good mRS score 0-2) in the heparin group 62% vs 66% Group 1 vs Group 2 p. 0.07 but did not reach statistical significance. Conclusions: Low dose heparin is safe and efficacies. Patients with aSAH secured b endovascular coiling who received low dose heparin infusion were noted to have better cognitive outcome scores. Randomised control trials are required to further delineate the role of heparin in these patients. Our studies weakness was its retrospective nature and limited patient volumes.