Effects of aspirin on stroke and mortality in tubercular meningitis: a meta-analysis of randomized controlled trials.

Background: Tubercular meningitis (TBM) remains a highly lethal form of extrapulmonary tuberculosis. Aspirin, owing to its anti-inflammatory and antithrombotic properties, has been explored as adjunctive therapy, but its clinical benefits remain controversial. This meta-analysis aimed to evaluate the efficacy and safety of adjunctive aspirin in TBM, particularly its impact on stroke and all-cause mortality, and to explore the influence of different aspirin dosages. Methods: We systematically searched four databases for randomized controlled trials (RCTs) comparing adjunctive aspirin versus standard anti-tuberculosis therapy (ATT) in TBM patients. Outcomes included stroke, all-cause mortality, and bleeding events. Random-effects meta-analyses were conducted to pool risk ratios (RRs) with 95% confidence intervals (CIs). A network meta-analysis (NMA) was performed to assess the effect of different aspirin doses. The quality of evidence was assessed using the GRADE framework. Results: Five RCTs involving 580 participants were included. Adjunctive aspirin significantly reduced the risk of stroke (RR: 0.56; 95% CI: 0.33-0.95), with low-dose aspirin showing superior protective effect compared to high-dose in NMA. However, aspirin did not reduce all-cause mortality (RR: 1.00; 95% CI: 0.65-1.55) or increase bleeding risk. Sensitivity analysis indicated limited robustness of stroke outcomes, and overall evidence quality ranged from low to very low. Conclusion: Adjunctive low-dose aspirin may reduce the risk of stroke in TBM without increasing bleeding events, although it has no clear effect on mortality. Further high-quality trials are needed to confirm the optimal dosing strategy and long-term benefits of aspirin in TBM management. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251110022, identifier CRD420251110022.