prasugrel-hydrochloride and Intracranial-Aneurysm

Prasugrel as a second generation P2Y12 adenosine diphosphate receptor antagonist which in the cerebral aneurysms with Endovascular treatment have become more emphasized.. To compare the efficacy and safety of prasugrel therapy for intracranial aneurysms with endovascular treatment.. The databases of PubMed, Embase, Cochrane Library databases and China Biology Medicine disc were retrieved with computers for collecting controlled trials about the comparison in the efficacy and safety of prasugrel and clopidogrel published from inception to September 2018. At the same time, the reference materials of included literature were retrieved manually. After rigorous evaluation on literature quality, the eligible data of the trials was extracted and given a Meta-analysis by applying RevMan5.3 software.. Of the 96 studies identified, 7 trials were included. Results of meta-analysis showed that compared with patients receiving clopidogrel treatment, novel platelet P2Y. In antiplatelet therapy after aneurysmal interventional therapy, the second generation of P2Y

Topics: Endovascular Procedures; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Treatment Outcome

The effectiveness and safety of low-dose prasugrel (PSG) premedication for endovascular treatment of unruptured intracranial aneurysms (UIAs) have been widely reported. In this study, we evaluated the clinical outcomes of elders patients (≥ 75 years) treated with PSG.. A total of 200 patients with 209 UIAs who were administered PSG as premedication (20 mg loading and 5 mg maintenance with 100 mg aspirin) between March 2018 and December 2021 were retrospectively enrolled. Among them, 39 patients were aged 75 years or over (elders group), and 161 patients were aged under 75 years (control group). Patients' clinical data were collected, and outcomes were compared between the two groups.. Of the 200 patients with PSG, 9 cases (4.5%) had overall complications (7 ischemic, 2 hemorrhagic). In the comparison between the elders group and the control group, no significant differences were observed in the overall complication rates (elders group vs. control group; 2.6% vs. 5.0%, P = 1.00). Moreover, the rates of poor clinical outcome were comparable (2.6% vs. 1.2%, P = 0.48). The subgroup analysis of patients with stent-assisted procedures revealed no significant differences in complication rates (0% vs. 1.6%, P = 1.00) or poor clinical outcomes (0% vs. 0%, P = 1.00) during maintenance with aspirin 100 mg or PSG 5 mg.. The complication rates in the elders treated with low-dose PSG premedication were similar to those in the control. Low-dose PSG premedication could be prescribed without any additional risk for the endovascular treatment of UIAs in elders patients.

Topics: Aged; Aspirin; Embolization, Therapeutic; Endovascular Procedures; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Stents; Treatment Outcome

Flow diversion treatment of ruptured cerebral aneurysms remains challenging due to the need for double-antiplatelet therapy. We report our experience with flow-diverter stent (FDS) reconstruction with single-antiplatelet therapy of ruptured cerebral blood blister and dissecting aneurysms.. In this case series we performed a retrospective analysis of all patients with ruptured cerebral aneurysms who were treated with a phosphoryl-bonded FDS between 2019 and 2022 in a single center. Periprocedurally, all patients received weight-adapted eptifibatide IV and heparin IV. After 6-24 hours, eptifibatide was switched to oral prasugrel as monotherapy. We analyzed the rate of bleeding complications, thromboembolic events, occlusion rate and clinical outcome.. Nine patients with subarachnoid hemorrhage were treated, eight within 24 hours of symptom onset. Seven patients were treated with one FDS and two patients received two FDS in a telescopic fashion. Two aneurysms were additionally coil embolized. Fatal re-rupture occurred in one case; eight patients survived and had no adverse events associated with the FDS. Six patients showed complete occlusion of the aneurysm after 3 months (n=2) and 1 year (n=4), respectively. Two patients showed subtotal occlusion of the aneurysm at the last follow-up after 3 months and 6 months, respectively. Favorable clinical outcome was achieved in five patients.. Peri-interventional single-antiplatelet therapy with eptifibatide followed by prasugrel was sufficient to prevent thromboembolic events and reduce re-bleeding using an anti-thrombogenic FDS. FDS with single-antiplatelet therapy might be a viable option for ruptured blood blister and dissecting cerebral aneurysms.

Topics: Aneurysm, Ruptured; Aortic Dissection; Blister; Embolization, Therapeutic; Endovascular Procedures; Eptifibatide; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Stents; Subarachnoid Hemorrhage; Treatment Outcome

Prophylactic prasugrel for endovascular treatment of intracranial aneurysms has been introduced and increased, but HTPR (high on-treatment platelet reactivity) or LTPR (low on-treatment platelet reactivity) of prasugrel is not uncommon in clinical circumstances. To investigate the predisposing factors of HTPR and LTPR on prasugrel premedication in the neurointerventional field and to determine its clinical implications.. Between February 2016 and December 2020, 191 patients treated with coil embolization using prophylactic prasugrel in 234 intracranial aneurysms were the final candidates for this study. Patient and aneurysm characteristics, clinical status, and laboratory study values were carefully reviewed retrospectively. We performed risk factor analyses for HTPR and LTPR on prasugrel.. Ultimately, 20 patients (10.5%) had HTPR, and 74 patients (38.7%) were categorized as having LTPR. In multivariable analyses, the factors related to HTPR were BMI (adjusted OR 1.21, 95% CI 1.04-1.41, p = 0.01), history of antithrombotics (adjusted OR 3.79, 95% CI 1.39-10.34, p = 0.01), and hematocrit (adjusted OR 0.91, 95% CI 0.84-0.99, p = 0.03). Low BMI was the only risk factor for LTPR (adjusted OR 0.84, 95% CI 0.76-0.94, p = 0.001).. In the neurointerventional field, high BMI and prior use of antithrombotic agents were related to HTPR, and low BMI was associated with LTPR on prophylactic prasugrel. High hematocrit levels decreased the risk of HTPR. When preparing endovascular treatment for intracranial aneurysms, attention to patients with these clinical features is required to address the possibility of ischemic or bleeding complications.

Topics: Clopidogrel; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Ticlopidine; Treatment Outcome

Much emphasis has been put on the use of antiplatelet medication for the prevention of ischemic events in the treatment of cerebral aneurysms with stent assistance. In this regard, the effectiveness and safety of a low-dose prasugrel regimen during the periprocedural period was recently reported. The purpose of this study was to present the outcomes of patients on low-dose prasugrel regimens during the follow-up period after stent-assisted coil embolization (SACE) of cerebral aneurysms.. For the 396 consecutive patients undergoing SACE procedures, low-dose prasugrel therapy (5 mg of prasugrel and 100 mg of aspirin) was recommended for 3 months after the endovascular treatment. The authors performed a retrospective review of a single-center experience focusing on delayed ischemic events beyond 1 month after treatment. The mean follow-up period was 24.6 ± 11.3 months.. In this cohort of patients on a low-dose prasugrel regimen, cerebral infarction occurred in 1 patient (0.3%, 95% CI 0%-1.8%) beyond 1 month after SACE. No intracranial hemorrhage occurred. Overall ischemic events occurred in 14 patients (3.5%, 95% CI 2.1%-5.9%), all within 6 months of the coiling procedure. All patients had transient symptoms. The events occurred within 2 months after cessation of prasugrel in 11 patients (78.6%). Prasugrel maintenance for 6 months was found to result in lower ischemic events compared with maintenance for 3 months.. For patients undergoing SACE, a low-dose prasugrel regimen was a safe and reliable treatment option for the prevention of delayed ischemic events. Transient ischemic events often occurred within 2 months of stopping prasugrel medication.

Topics: Embolization, Therapeutic; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Stents; Treatment Outcome

Aneurysm treatment using the Pipeline Embolization Device has been established but appropriate maintenance of dual antiplatelet therapy (APT) is essential. This multicenter retrospective study assessed whether APT was properly adjusted for clopidogrel resistance and identified risk factors associated with periprocedural complications.. Consecutive cases of use of the Pipeline Embolization Device for internal carotid artery aneurysms (>10 mm) between November 2015 and April 2020 were analyzed. Dual APT (aspirin + clopidogrel) was prescribed before treatment. If preprocedural P2Y12 reaction unit (PRU) values were >240, APT was adjusted. Periprocedural complications were compared between APT nonadjustment and adjustment groups and periprocedural risk factors were also analyzed.. A total of 162 procedures were assessed. The mean maximum aneurysm size was 15.35 mm. APT adjustment was required in 47 cases (29.0%), primarily by switching to prasugrel. There were no significant differences in complication incidence between the 2 groups even after propensity score matching. The risk factor independently associated with ischemic complications was a neck size of 8 mm or larger (odds ratio [OR], 5.25; P = 0.018) and restricting analysis to the APT nonadjustment group showed PRU values of 190 or higher (OR, 5.84; P = 0.047) and neck sizes of 8 mm or larger (OR, 7.05; P = 0.029) as significant factors. The risk factor independently associated with hemorrhagic complications was a neck size of 7 mm or larger (OR, 11.57; P = 0.023).. APT adjustment for clopidogrel resistance was safe and effective. Neck width was a risk factor for both ischemic and hemorrhagic complications. PRU values of 190 or higher were also associated with ischemic complications.

Topics: Adult; Aged; Aspirin; Carotid Artery, Internal; Clopidogrel; Dual Anti-Platelet Therapy; Embolization, Therapeutic; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Perioperative Care; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Risk Factors

To assess the safety and short-term occlusion rates in procedures using the p64 MW hydrophilic polymer-coated (HPC) flow diverter (FD) with prasugrel single antiplatelet therapy (SAPT) for the treatment of anterior circulation saccular aneurysms.. We retrospectively identified patients who underwent treatment of one or more intracranial anterior circulation saccular aneurysms between March 2020 and December 2021 with a p64 MW HPC FD and prasugrel SAPT with verified P2Y12 platelet receptor inhibition. Patients diagnosed with fusiform, dissecting, or recently ruptured aneurysms were excluded. Periprocedural and postprocedural complications, clinical outcomes, and angiographic follow-up results were evaluated.. One hundred and two patients with 132 intracranial aneurysms met the inclusion criteria. Previous or concomitant treatments (e.g., coil occlusion) had been performed on 18 of these aneurysms. The technical success rate (i.e., implantation of the intended FD) was 100% with an average of 1.1 devices implanted per patient. Periprocedural and postprocedural complications occurred in 13.6% and 6.8% of these patients, respectively. No mortality or permanent clinical deterioration (i.e., modified Rankin scale score ≥ 3) were reported. Early follow-up digital subtraction angiography revealed aneurysmal occlusion rates of 72.6% and 83.8% at four and nine months, respectively.. The implantation of a p64 MW HPC FD with prasugrel SAPT is safe and results in rapid, reliable and effective aneurysmal occlusion.

Topics: Embolization, Therapeutic; Endovascular Procedures; Follow-Up Studies; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Polymers; Prasugrel Hydrochloride; Retrospective Studies; Stents; Treatment Outcome

Flow diverters (FDs) are effective in the treatment of carotid aneurysms. Compared with carotid aneurysms, the treatment of distal intracranial aneurysms with FDs has been associated with a relatively high incidence of complications. Low thrombogenic modified-surface FDs may reduce ischemic complications and allow for the use of a single antiplatelet medication. The aim of this study was to assess the safety and efficacy of the p48 MW HPC Flow Modulation Device (Phenox GmbH, Bochum, Germany) to treat distal intracranial aneurysms used in combination with prasugrel monotherapy.. This was a single-center, prospective, pivotal, open, single-arm study. Patients were included in this study from December 2019 to September 2020. The primary endpoints were the incidence of any neurologic deficit after treatment until 1 month of follow-up, defined as National Institutes of Health Stroke Scale (NIHSS) ≥1, and the incidence of acute ischemic lesions in magnetic resonance imagin (MRI) images 48 hours after treatment. The secondary endpoint was the rate of complete occlusion of the aneurysms at the 1-month follow-up.. Twenty-one patients harboring 27 distal aneurysms of the anterior circulation were included. Mean age was 57.8 (SD 9.7) years, and 16 patients were female (80%). No patient had neurologic symptoms at the 1-month follow-up. Four patients (20%) had asymptomatic acute brain ischemic lesions on MRI. Complete aneurysm occlusion occurred in 9/27 (33.3%) aneurysms at the 1-month follow-up.. In this pilot safety trial, treatment of distal intracranial aneurysms with p48 MW HPC under monotherapy with prasugrel appeared to be safe.

Topics: Adult; Aged; Embolization, Therapeutic; Endovascular Procedures; Female; Follow-Up Studies; Humans; Intracranial Aneurysm; Magnetic Resonance Imaging; Male; Middle Aged; Pilot Projects; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Prospective Studies; Self Expandable Metallic Stents; Treatment Outcome

Thromboembolic complications (TECs) are frequent during the endovascular treatment of unruptured aneurysms. To prevent TECs, dual antiplatelet therapy using aspirin and clopidogrel is recommended for the perioperative period. In patients with a poor response, clopidogrel is a risk factor for TECs. To prevent TECs, our study assessed the stratified use of prasugrel.. Patients who underwent endovascular therapy for unruptured cerebral aneurysms from April 2017 to August 2019 were enrolled in this clinical study and given premedication with aspirin and clopidogrel for 2 weeks prior to the procedure. P2Y12 reaction units (PRU) were measured using the VerifyNow assay on the day before the procedure (tailored group). In subgroups with PRU <240, the clopidogrel dose was maintained (CPG subgroup). In subgroups with PRU ≥240, clopidogrel was changed to prasugrel (PSG subgroup). We compared the occurrence of TECs with retrospective consecutive cases from January 2015 to March 2017 without PRU assessments (non-tailored group). The frequency of TECs within 30 days was assessed as the primary endpoint.. The tailored and non-tailored groups comprised 167 and 50 patients, respectively. TECs occurred in 11 (6.6%) and 8 (16%) patients in the tailored and non-tailored groups (P=0.048), respectively. The HR for TECs was significantly reduced in the tailored group (HR 0.3, 95% CI 0.11 to 0.81); P=0.017) compared with the non-tailored group.. The results suggest that tailored dual antiplatelet therapy medication with PRU significantly reduces the frequency of TECs without increasing hemorrhagic complications.

Topics: Aspirin; Humans; Intracranial Aneurysm; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies

A patient undergoes intracranial stent insertion for stent-assisted coiling of a basilar tip aneurysm and left middle cerebral artery aneurysm. A flow diverting stent is also placed across an anterior communicating artery aneurysm. Prior to the procedure, the patient takes dual antiplatelet medications, being aspirin and clopidogrel. Because of the concern regarding in-stent thrombus and thromboembolic complications related to intracranial stenting and the high rate of clopidogrel resistance, preoperative platelet function testing (PFT) was undertaken to ensure platelet inhibition. In this case, PFT was performed on a platelet function analyser which demonstrated platelet inhibition. Ten days following the procedure, the patient represented with thromboembolic stroke. Repeat PFT performed with whole blood impedance aggregometry and despite full medication compliance demonstrated clopidogrel resistance. Clopidogrel was then ceased and prasugrel commenced. This case demonstrates the importance of appropriate platelet inhibition in patients with intracranial stents and the controversy surrounding PFT.

Topics: Aged; Aspirin; Clopidogrel; Diagnosis, Differential; Drug Resistance; Humans; Intracranial Aneurysm; Ischemic Attack, Transient; Magnetic Resonance Imaging; Male; Platelet Aggregation Inhibitors; Platelet Function Tests; Prasugrel Hydrochloride; Preoperative Care; Stents; Stroke; Thromboembolism; Treatment Outcome; Withholding Treatment

In patients requiring stent procedures, resistance or hyperresponsiveness to antiplatelet medications is often observed. This study aims to evaluate the efficacy and safety of tailoring medications in these patients.. This retrospective study included 223 patients who underwent endovascular treatment for intracranial aneurysm between October 2018 and October 2019. Patients were categorized as hyporesponsive, hyperresponsive, and normoresponsive groups according to the initial PRU response. For the hypo- or hyperresponders, we tailored medication by modifying the dose or changing the drug. PRUs before and after tailoring were compared in each group. PRU reponses in patients who underwent Cytochrome P450 2C19 (CYP2C19) genotyping were also determined.. Of the 73 clopidogrel-resistant patients, the mean PRU values after tailoring showed a greater decrease in the group that switched to prasugrel (n = 56), from 223 to 131, than in the clopidogrel reloading group (n = 17), from 238 to 209. In 31 hyperresponders, PRU increased from 49 to 94 after the dose adjustment. CYP2C19 genotyping showed that PRU tended to increase as the number of mutated alleles increased. There were five (2.3%) ischemic events (three transient ischemic attacks and two minor strokes) in a mean follow-up of 8 months, but no hemorrhage.. The stent-assisted coiling was successfully performed with acceptable range of ischemic events and without hemorrhage in all patients, including those who applied tailored medication. Low-dose prasugrel was effective for obtaining appropriate PRU values for initial medication as well as for clopidogrel-resistant patients. The genetic test did not provide reliable results in determining clopidogrel resistance.

Topics: Clopidogrel; Combined Modality Therapy; Cytochrome P-450 CYP2C19; Embolization, Therapeutic; Female; Genotype; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Stents

The aim of this study was to determine whether half-dose loading (30 mg) of prasugrel is sufficient to achieve adequate platelet inhibition, and whether such a loading dose of prasugrel together with aspirin followed by a 10 mg/day prasugrel maintenance, could serve as a first-line antiplatelet strategy for patients undergoing flow-diverting stent (FDS) implantation.. Data from a group of consecutive patients treated for intracranial aneurysm with FDS were retrospectively collected. Platelet P2Y12 receptor responsiveness was assessed by a rapid platelet function test just prior to the procedure. All ischemic and hemorrhagic complications as well as morbidity and mortality rates were documented.. A total of 138 patients with 153 aneurysms (32 were symptomatic and 121 were incidental) underwent FDS treatment in a total of 147 loading sessions. Adequate platelet inhibition was obtained in 136/138 (98.5%) patients and 145/147 (98.6%) loading sessions. Overall, there was one case of (hemorrhagic) mortality (0.7%), one of (ischemic) morbidity (0.7%), one of symptomatic (hemorrhagic) clinical complications without permanent deficits (0.7%), and six transient ischemic attacks (4.1%). The 6‑month control angiography, available for all patients, revealed a 95.4% aneurysm occlusion rate.. Half-dose (30 mg) prasugrel loading results in effective platelet P2Y12 receptor inhibition in more than 98% of patients. Dual antiaggregant loading with half dose prasugrel followed by prasugrel maintenance as a first-line therapy appears to be feasible in patients treated with FDS implantation for intracranial aneurysm.

Topics: Aspirin; Cerebral Angiography; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Stents

Antiplatelet premedication is widely accepted for interventional treatment of cerebral aneurysms to prevent thromboembolism. However, antiplatelet resistance sometimes limits the effectiveness of premedication.. To compare 2 groups administered low-dose prasugrel (PSG group) or clopidogrel-based tailored antiplatelet (CPG group) in terms of platelet function and procedure-related complications.. A total of 411 patients with 505 unruptured aneurysms who underwent endovascular treatment within the past 17 mo were retrospectively enrolled in this study. The PSG (225 patients with 277 aneurysms) and CPG groups (186 patients with 228 aneurysms) were administered the respective medication prior to endovascular treatment. We measure the response to the antiplatelet medication with a laboratory test. Episodes of periprocedural bleeding and thromboembolism were compared between the 2 groups.. There were significant differences between the 2 groups in terms of the mean P2Y12 reaction unit values (125.7 in the PSG group vs 251.0 in the CPG group; P < .001) and percentage inhibition (57.8% vs 18.7%, respectively; P < .001). Drug resistance was 29.6% per patient in the CPG group and 2.7% per patient in the PSG group. The PSG group reported 1 thromboembolism and bleeding each; meanwhile, the CPG group reported 7 thromboembolism and 3 bleeding. Compared to clopidogrel administration, prasugrel administration significantly decreased the risk of thromboembolism (weighted hazard ratio, 0.17; 95% confidence interval, 0.03-0.99). However, the risk of bleeding was not significant.. Prasugrel was found to be more effective in reducing periprocedural thromboembolism compared to clopidogrel.

Topics: Aged; Clopidogrel; Endovascular Procedures; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prasugrel Hydrochloride; Premedication; Retrospective Studies; Thromboembolism

OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016. Patients allergic, or having less than 30% platelet inhibition, to a daily 75-mg dose of clopidogrel received 10 mg of prasugrel daily (n = 20) or 90 mg of ticagrelor twice daily (n = 2). The mean (± SD) follow-up duration was 15.8 ± 12.4 months. The primary outcome was the modified Rankin Scale (mRS) score registered before discharge and at each follow-up visit. To control confounding, multivariable mixed-effects logistic regression and propensity score conditioning were used.RESULTSTwenty-six (5.9%) of 437 patients presented with a subarachnoid hemorrhage (SAH). The mean patient age was 56.3 years, and 62 were women (14.2%). One of the 7 patients lost to follow-up received prasugrel. One patient was allergic to clopidogrel and prasugrel simultaneously. All patients receiving prasugrel or ticagrelor (n = 22) had an mRS score ≤ 2 on their latest follow-up visit (mean score 0.67 ± 1.15). In a multivariate analysis, clopidogrel did not affect the mRS score on last follow-up (p = 0.14). Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (OR 0.17, 95% CI 0.01-2.70, p = 0.21), an increased thromboembolic complication rate (OR 0.46, 95% CI 0.12-1.67, p = 0.24), or an increased hemorrhagic event rate (OR 0.39, 95% CI 0.91-1.64, p = 0.20). None of the patients receiving prasugrel or ticagrelor died or suffered a long-term recurrence or a hemorrhagic event; only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. Three patients taking clopidogrel died during the study: 2 from acute SAH and 1 from intraparenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR 2.18, 95% CI 0.11-43.27, p = 0.61). The same associations were present in propensity score-adjusted models.CONCLUSIONSIn a cohort of patients treated with PEDs, prasugrel (10 mg/day) was a safe alternative to clopidogrel-resistant or clopidogrel-allergic patients, or nonresponders.

Topics: Adult; Aged; Embolization, Therapeutic; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Subarachnoid Hemorrhage; Treatment Outcome

The use of antiplatelet medications to prevent thrombosis in the treatment of cerebral aneurysms with stents has become widely emphasized.. To compare low-dose prasugrel with clopidogrel in stent-assisted coil embolization of intracranial aneurysms.. This is a retrospective review of 311 aneurysms from 297 patients who underwent stent-assisted endovascular coil embolization of unruptured intracranial aneurysm between November 2014 and March 2017. Thromboembolic and hemorrhagic adverse events were compared between 207 patients who received low-dose prasugrel (PSG group) and 90 patients who received clopidogrel (CPG group).. P2Y12 reaction unit (PRU) values were significantly lower in the PSG group (PSG group vs CPG group, 132.3 ± 76.9 vs 238.1 ± 69.1; P < .001); the percentage of inhibition was also statistically higher in the PSG group (54.0 ± 26.0% vs 20.8 ± 18.6%; P < .001). Thromboembolic events occurred less frequently in the PSG group than in the CPG group (0.9% vs 6.4%; P = .01), whereas there was no significant difference in the percentage of hemorrhagic complications (0.5% vs 2.2%; P = .22). In the multivariate analysis, clopidogrel as the antiplatelet medication was the sole significant risk factor for thromboembolism in this series of patients undergoing stent-assisted coil embolization.. Use of low-dose PSG as an antiplatelet premedication is quick, effective, and safe for stent-assisted coil embolization of unruptured intracranial aneurysms. Prasugrel premedication significantly lowered the frequency of thromboembolic events without increasing the risk of hemorrhage.

Topics: Adult; Aged; Clopidogrel; Embolization, Therapeutic; Endovascular Procedures; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Premedication; Retrospective Studies; Risk Factors; Stents; Thromboembolism

Blister like aneurysm (BLA) is extremely challenging to treat; endoluminal reconstruction has emerged as the most promising treatment method. When to treat after the ictus, the timing of administration of antiplatelet and causal relationship between platelet function testing results and thrombo-embolism is unclear. We theorized that Prasugrel with a lower incidence of resistance may be a safe suitable alternative to clopidogrel in patients treated with a flow diverter (FD).. Prospectively collected data from consecutive patients treated for a ruptured blister with an FD was reviewed. Device deployment was timed to be at 2 h following Prasugrel loading. Thrombo-embolic and hemorrhagic complications, and occlusion rates were documented.. Nine patients were included. Most were females (55%); the median age was 55 (43, 65). The median Fischer grade was 3 (2, 4). A single pipeline device was deployed in all within 24 h of admission; the median time from ictus to device deployment was 4 days (2, 30). There were no thrombo-embolic or hemorrhagic complication. Complete occlusion was noted in 89% (n = 9).. Prasugrel loading timed 2 h prior to stent delivery did not increase thrombo-embolic or hemorrhagic complications. Single stent that is well apposed against the wall appears to be an effective treatment strategy to treat BLA. Advances in knowledge: Treatment of acutely ruptured BLA with a single pipeline device deployed at 2 h after Prasugrel loading appears to be safe.

Topics: Adult; Aged; Aneurysm, Ruptured; Embolization, Therapeutic; Female; Hemorrhage; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Retrospective Studies; Stents; Thromboembolism; Treatment Outcome

Background Thromboembolic complications are the main problem in stent-assisted coil embolization of unruptured intracranial aneurysms. The combination of aspirin and clopidogrel is generally used to decrease these complications, but some patients do not respond to clopidogrel and have a higher risk of stent thrombosis. In cardiology, clinical trials have shown that prasugrel reduced the incidence of ischaemic events in patients with acute coronary syndrome compared with clopidogrel but, according to several authors, prasugrel would produce an increased risk of cerebral haemorrhagic complications. Objective The purpose of this study was to determine whether prasugrel would be more effective than clopidogrel in reducing procedural events in patients with an unruptured aneurysm treated endovascularly with coils and stent. Materials and methods Two hundred consecutive patients with intracranial aneurysms were treated using coiling and stenting procedures. The first 100 patients were administered a dual antiplatelet of aspirin and clopidogrel, while the remaining 100 patients were administered a dual antiplatelet of aspirin and prasugrel. In each group data were collected on procedural and periprocedural haemorrhagic and ischaemic complications. Results Aneurysmal occlusion and haemorrhagic complications rates were identical in both groups. The number of thromboembolic events observed in the two groups of our study did not differ significantly, but the prasugrel group included more wide-neck aneurysms and more flow-diverted stents. Moreover, complications in the prasugrel group were more benign, explaining the significant difference in clinical outcomes between the two groups on Day 30. Conclusions Prasugrel reduces the clinical consequences of thromboembolic complications of endovascular treatment with stenting and coiling of unruptured intracranial aneurysms.

Topics: Adult; Aged; Aspirin; Clopidogrel; Combined Modality Therapy; Drug Therapy, Combination; Embolization, Therapeutic; Female; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Postoperative Complications; Prasugrel Hydrochloride; Stents; Ticlopidine; Treatment Outcome

Platelet function testing is controversial and not well studied in patients with neurovascular disease.. To evaluate the performance of thromboelastography (TEG) as a platelet function test in neurovascular patients treated with the Pipeline embolization device (PED).. A prospective protocol was instituted for platelet function testing in patients undergoing repair of intracranial aneurysms with the PED. All patients received dual antiplatelet therapy (DAT) and their response to both P2Y12 inhibitors and aspirin was quantified with TEG. Each patient's DAT induction strategy was tailored based on the percentage ADP-induced and percentage arachidonic acid-induced platelet inhibition reported by TEG. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Patients were followed up clinically and/or angiographically at 30 days, 6 months, and 1 year.. Thirty-four PED procedures were performed on 31 patients. TEG results altered the DAT strategy in 35% of patients. Technical success with the Pipeline placement was 100%. Two patients had minor strokes and five had transient ischemic attacks (TIAs). There have been no hemorrhagic complications. No patient had permanent neurologic deficits. Six of eight (75%) of patients with thromboembolic/TIA events were ADP-induced hyporesponders by TEG. Our 6- and 12-month angiographic occlusion rates were 78.9% and 89.5%, respectively. The 19 major branches covered by the PED that were assessed by follow-up imaging have all remained patent.. Platelet function testing with TEG altered our DAT induction strategy in a significant number of cases. No hemorrhagic or disabling thromboembolic complications were seen in this series. Future studies should compare methods of platelet function testing and, possibly, no platelet function testing in neurovascular patients undergoing flow diversion and/or stent-assisted treatment of intracranial aneurysms.

Topics: Adult; Aged; Aged, 80 and over; Aspirin; Blood Vessel Prosthesis; Clopidogrel; Drug Therapy, Combination; Embolization, Therapeutic; Female; Follow-Up Studies; Humans; Intracranial Aneurysm; Male; Middle Aged; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Purinergic P2Y Receptor Antagonists; Thrombelastography; Ticlopidine; Treatment Outcome

Topics: Adult; Aneurysm, Ruptured; Behcet Syndrome; Cerebral Hemorrhage; Combined Modality Therapy; Coronary Aneurysm; Coronary Restenosis; Drug-Eluting Stents; Humans; Intracranial Aneurysm; Male; Myocardial Ischemia; Piperazines; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Rupture, Spontaneous; Stents; Thiophenes

Prevention of intracranial stent thrombosis with dual-antiplatelet therapy is widely used in neuroendovascular procedures. However, the rising incidence of inadequate platelet inhibition with clopidogrel may increase complications following stent placement, especially with newer devices that possess a larger total metal surface area. While there are recent reports of prasugrel as an alternative to clopidogrel, there is no clinical evidence in neurointerventional patients regarding the use of a lower maintenance dose as an alternative strategy to gain adequate platelet inhibition while possibly reducing the risk of bleeding. We present 6-month efficacy and safety outcomes of two patients undergoing elective pipeline embolisation that were found to have inadequate platelet response to clopidogrel and subsequently transitioned to prasugrel 5 mg daily for the prevention of stent thrombosis.

Topics: Carotid Artery, Internal, Dissection; Cerebral Angiography; Clopidogrel; Embolization, Therapeutic; Female; Follow-Up Studies; Humans; Intracranial Aneurysm; Middle Aged; Piperazines; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Purinergic P2Y Receptor Antagonists; Receptors, Purinergic P2Y12; Stents; Thiophenes; Thrombosis; Ticlopidine; Treatment Outcome

Prevention of intracranial stent thrombosis with dual-antiplatelet therapy is widely used in neuroendovascular procedures. However, the rising incidence of inadequate platelet inhibition with clopidogrel may increase complications following stent placement, especially with newer devices that possess a larger total metal surface area. While there are recent reports of prasugrel as an alternative to clopidogrel, there is no clinical evidence in neurointerventional patients regarding the use of a lower maintenance dose as an alternative strategy to gain adequate platelet inhibition while possibly reducing the risk of bleeding. We present 6-month efficacy and safety outcomes of two patients undergoing elective pipeline embolisation that were found to have inadequate platelet response to clopidogrel and subsequently transitioned to prasugrel 5 mg daily for the prevention of stent thrombosis.

Topics: Blood Platelets; Clopidogrel; Embolization, Therapeutic; Female; Hemorrhage; Humans; Intracranial Aneurysm; Intracranial Thrombosis; Middle Aged; Piperazines; Platelet Aggregation Inhibitors; Prasugrel Hydrochloride; Stents; Thiophenes; Ticlopidine; Treatment Outcome