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Safety and efficacy of a pre-treatment antiplatelet regimen of unruptured intracranial aneurysms: a single-center experience

  • Interventional Neuroradiology
  • Published:
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Abstract

Purpose

Endovascular treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents requires a prophylactic antiplatelet premedication to avoid thrombo-embolic complications. Guidelines for optimal antiplatelet regimens are poorly defined. The aim of this study is to report our experience using a high dosage antiplatelet premedication regimen for patients with unruptured intracranial aneurysms undergoing endovascular treatment by stent-assisted coiling or flow diverter stents.

Methods

From a retrospective analysis of a prospectively maintained database, we collected clinical and angiographic data of 400 procedures in 362 patients treated by stent-assisted coiling or flow diverter stents for 419 unruptured intracranial aneurysms. Descriptive and analytic statistics were performed to report morbidity, mortality, and complication rates and to demonstrate associations between variables and outcomes. Logistic multivariable regression was performed to rule out confounding factors between subgroups.

Results

Thrombo-embolic complications occurred in 23/400 procedures (5.75%) and hemorrhagic complications in 19/400 procedures (4.75%). The majority of complications were minor and transient with overall procedure-related morbidity and mortality rates of 1.75% (n = 7/400) and 1.25% (n = 5/400) respectively. The co-existence of multiple cardiovascular risk factors among smoking, hypertension, dyslipidemia, and age > 65 years old was significantly associated with permanent procedure-related morbidity (p = 0.006) and thrombo-embolic complications occurrence (p = 0.034). Age alone was associated with higher permanent morbidity (p = 0.029) and was the only variable associated with higher hemorrhagic complication (p = 0.024).

Conclusion

In this study, the use of a high dosage antiplatelet premedication was safe and effective for the treatment of unruptured intracranial aneurysms with stent-assisted coiling or flow diverter stents. Mortality and morbidity rates compare favorably with the current literature. The thrombo-embolic complications rate is low and most of them were clinically silent. However, the hemorrhagic complications rate was substantial and a significant proportion of them were associated with mortality.

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Abbreviations

EVT:

Endovascular treatment

TE:

Thrombo-embolic

ST:

Stenting techniques

HH:

Hemorrhagic

SAC:

Stent-assisted coiling

FD:

Flow diverter

ACT:

Activated clotting time

AP:

Antiplatelet

INR:

Interventional neuroradiology

UIA:

Unruptured intracranial aneurysm

mRS:

Modified Rankin Score

CV:

Cardiovascular

References

  1. Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SCC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J, American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention, American Heart Association, American Stroke Association (2015) Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 46:2368–2400. https://doi.org/10.1161/STR.0000000000000070

    Article  PubMed  Google Scholar 

  2. Molyneux AJ, RSC K, Yu L-M, Clarke M, Sneade M, Yarnold JA, Sandercock P, International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366:809–817. https://doi.org/10.1016/S0140-6736(05)67214-5

    Article  Google Scholar 

  3. Lv X, Yang H, Liu P, Li Y (2016) Flow-diverter devices in the treatment of intracranial aneurysms: a meta-analysis and systematic review. Neuroradiol J 29:66–71. https://doi.org/10.1177/1971400915621321

    Article  PubMed  PubMed Central  Google Scholar 

  4. Kim KS, Fraser JF, Grupke S, Cook AM (2018) Management of antiplatelet therapy in patients undergoing neuroendovascular procedures. J Neurosurg 129:890–905. https://doi.org/10.3171/2017.5.JNS162307

    Article  CAS  PubMed  Google Scholar 

  5. Faught RWF, Satti SR, Hurst RW, Pukenas BA, Smith MJ (2014) Heterogeneous practice patterns regarding antiplatelet medications for neuroendovascular stenting in the USA: a multicenter survey. J Neurointerv Surg 6:774–779. https://doi.org/10.1136/neurintsurg-2013-010954

    Article  PubMed  Google Scholar 

  6. Shim EJ, Ryu C-W, Park S, Lee HN, Shin HS, Kim S-B (2018) Relationship between adverse events and antiplatelet drug resistance in neurovascular intervention: a meta-analysis. J Neurointerv Surg. https://doi.org/10.1136/neurintsurg-2017-013632

  7. Mehran R, Rao SV, Bhatt DL, Gibson CM, Caixeta A, Eikelboom J, Kaul S, Wiviott SD, Menon V, Nikolsky E, Serebruany V, Valgimigli M, Vranckx P, Taggart D, Sabik JF, Cutlip DE, Krucoff MW, Ohman EM, Steg PG, White H (2011) Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation 123:2736–2747. https://doi.org/10.1161/CIRCULATIONAHA.110.009449

    Article  PubMed  Google Scholar 

  8. Fifi JT, Brockington C, Narang J, Leesch W, Ewing SL, Bennet H, Berenstein A, Chong J (2013) Clopidogrel resistance is associated with thromboembolic complications in patients undergoing neurovascular stenting. AJNR Am J Neuroradiol 34:716–720. https://doi.org/10.3174/ajnr.A3405

    Article  CAS  PubMed  Google Scholar 

  9. Yang H, Li Y, Jiang Y (2016) Insufficient platelet inhibition and thromboembolic complications in patients with intracranial aneurysms after stent placement. J Neurosurg 125:247–253. https://doi.org/10.3171/2015.6.JNS1511

    Article  PubMed  Google Scholar 

  10. Shapiro M, Becske T, Sahlein D, Babb J, Nelson PK (2012) Stent-supported aneurysm coiling: a literature survey of treatment and follow-up. AJNR Am J Neuroradiol 33:159–163. https://doi.org/10.3174/ajnr.A2719

    Article  CAS  PubMed  Google Scholar 

  11. Kim DJ, Suh SH, Kim BM, Kim DI, Huh SK, Lee JW (2010) Hemorrhagic complications related to the stent-remodeled coil embolization of intracranial aneurysms. Neurosurgery 67:73–78; discussion 78-79. https://doi.org/10.1227/01.NEU.0000370937.70207.95

    Article  PubMed  Google Scholar 

  12. White AC, Kumpe DA, Roark CD, Case DE, Seinfeld J (2018) Patterns, predictors, and outcomes of postprocedure delayed hemorrhage following flow diversion for intracranial aneurysm treatment. World Neurosurg 115:e97–e104. https://doi.org/10.1016/j.wneu.2018.03.190

    Article  PubMed  Google Scholar 

  13. Phan K, Huo YR, Jia F, Phan S, Rao PJ, Mobbs RJ, Mortimer AM (2016) Meta-analysis of stent-assisted coiling versus coiling-only for the treatment of intracranial aneurysms. J Clin Neurosci 31:15–22. https://doi.org/10.1016/j.jocn.2016.01.035

    Article  PubMed  Google Scholar 

  14. Wang F, Chen X, Wang Y, Bai P, Wang H-Z, Sun T, Yu H-L (2016) Stent-assisted coiling and balloon-assisted coiling in the management of intracranial aneurysms: a systematic review & meta-analysis. J Neurol Sci 364:160–166. https://doi.org/10.1016/j.jns.2016.03.041

    Article  PubMed  Google Scholar 

  15. Adeeb N, Griessenauer CJ, Foreman PM, Moore JM, Shallwani H, Motiei-Langroudi R, Alturki A, Siddiqui AH, Levy EI, Harrigan MR, Ogilvy CS, Thomas AJ (2017) Use of platelet function testing before pipeline embolization device placement: a multicenter cohort study. Stroke 48:1322–1330. https://doi.org/10.1161/STROKEAHA.116.015308

    Article  PubMed  Google Scholar 

  16. Skukalek SL, Winkler AM, Kang J, Dion JE, Cawley CM, Webb A, Dannenbaum MJ, Schuette AJ, Asbury B, Tong FC (2016) Effect of antiplatelet therapy and platelet function testing on hemorrhagic and thrombotic complications in patients with cerebral aneurysms treated with the pipeline embolization device: a review and meta-analysis. J Neurointerv Surg 8:58–65. https://doi.org/10.1136/neurintsurg-2014-011145

    Article  PubMed  Google Scholar 

  17. Oran I, Cinar C, Bozkaya H, Korkmaz M (2015) Tailoring platelet inhibition according to multiple electrode aggregometry decreases the rate of thrombotic complications after intracranial flow-diverting stent implantation. J Neurointerv Surg 7:357–362. https://doi.org/10.1136/neurintsurg-2013-011023

    Article  PubMed  Google Scholar 

  18. Hwang G, Huh W, Lee JS, Villavicencio JB, Villamor RBV, Ahn SY, Kim J, Chang JY, Park SJ, Park N-M, Jeong E-A, Kwon O-K (2015) Standard vs modified antiplatelet preparation for preventing thromboembolic events in patients with high on-treatment platelet reactivity undergoing coil embolization for an unruptured intracranial aneurysm: a randomized clinical trial. JAMA Neurol 72:764–772. https://doi.org/10.1001/jamaneurol.2015.0654

    Article  PubMed  Google Scholar 

  19. Tantry US, Bonello L, Aradi D, Price MJ, Jeong Y-H, Angiolillo DJ, Stone GW, Curzen N, Geisler T, Ten Berg J, Kirtane A, Siller-Matula J, Mahla E, Becker RC, Bhatt DL, Waksman R, Rao SV, Alexopoulos D, Marcucci R, Reny J-L, Trenk D, Sibbing D, Gurbel PA, Working Group on On-Treatment Platelet R (2013) Consensus and update on the definition of on-treatment platelet reactivity to adenosine diphosphate associated with ischemia and bleeding. J Am Coll Cardiol 62:2261–2273. https://doi.org/10.1016/j.jacc.2013.07.101

    Article  CAS  PubMed  Google Scholar 

  20. Nguyen TA, Diodati JG, Pharand C (2005) Resistance to clopidogrel: a review of the evidence. J Am Coll Cardiol 45:1157–1164. https://doi.org/10.1016/j.jacc.2005.01.034

    Article  CAS  PubMed  Google Scholar 

  21. Brinjikji W, Lanzino G, Cloft HJ, Siddiqui AH, Hanel RA, Kallmes DF (2015) Platelet testing is associated with worse clinical outcomes for patients treated with the pipeline embolization device. AJNR Am J Neuroradiol 36:2090–2095. https://doi.org/10.3174/ajnr.A4411

    Article  CAS  PubMed  Google Scholar 

  22. Drazin D, Choulakian A, Nuño M, Kornbluth P, Alexander MJ (2011) Body weight: a risk factor for subtherapeutic antithrombotic therapy in neurovascular stenting. J Neurointerv Surg 3:177–181. https://doi.org/10.1136/jnis.2010.004085

    Article  PubMed  Google Scholar 

  23. Atallah E, Saad H, Bekelis K, Chalouhi N, Tjoumakaris S, Hasan D, Zarzour H, Smith M, Rosenwasser RH, Jabbour P (2017) Safety and efficacy of a 600-mg loading dose of clopidogrel 24 hours before pipeline embolization device treatment. World Neurosurg 106:529–535. https://doi.org/10.1016/j.wneu.2017.07.019

    Article  PubMed  Google Scholar 

  24. Zaidat OO (2009) Periprocedural management of patients with endovascular treatment of intracranial atherosclerotic disease. J Neuroimaging 19(Suppl 1):35S–38S. https://doi.org/10.1111/j.1552-6569.2009.00421.x

    Article  PubMed  Google Scholar 

  25. Gurbel PA, Bliden KP, Butler K, Antonino MJ, Wei C, Teng R, Rasmussen L, Storey RF, Nielsen T, Eikelboom JW, Sabe-Affaki G, Husted S, Kereiakes DJ, Henderson D, Patel DV, Tantry US (2010) Response to ticagrelor in clopidogrel nonresponders and responders and effect of switching therapies: the RESPOND study. Circulation 121:1188–1199. https://doi.org/10.1161/CIRCULATIONAHA.109.919456

    Article  CAS  PubMed  Google Scholar 

  26. Sedat J, Chau Y, Gaudart J, Sachet M, Beuil S, Lonjon M (2017) Prasugrel versus clopidogrel in stent-assisted coil embolization of unruptured intracranial aneurysms. Interv Neuroradiol 23:52–59. https://doi.org/10.1177/1591019916669090

    Article  PubMed  Google Scholar 

  27. Aquarius R, de Korte A, Smits D, Gounis M, Verrijp K, Driessen L, Leenders W, de Vries J (2018) The importance of wall apposition in flow diverters. Neurosurgery. https://doi.org/10.1093/neuros/nyy092

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Acknowledgements

A special thanks is dedicated to Pr Charles Strother (University of Wisconsin) for his precious assistance and advice.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Hôpital Erasme, Université Libre de Bruxelles (ULB), 808, Route de Lennik, 1070, Brussels, Belgium

    Anthony Peret, Benjamin Mine, Thomas Bonnet, Noémie Ligot & Boris Lubicz

  2. Service de la Recherche Biomédicale, Université Libre de Bruxelles (ULB), 808, Route de Lennik, 1070, Brussels, Belgium

    Jason Bouziotis

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  1. Anthony Peret
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Correspondence to Anthony Peret.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

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Appendix. Complications mRS reports

Appendix. Complications mRS reports

Table 13 Thrombo-embolic and hemorrhagic complication
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Table 14 Hemorrhagic complications
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Table 15 Thrombo-embolic complications
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Peret, A., Mine, B., Bonnet, T. et al. Safety and efficacy of a pre-treatment antiplatelet regimen of unruptured intracranial aneurysms: a single-center experience. Neuroradiology 62, 1029–1041 (2020). https://doi.org/10.1007/s00234-020-02387-y

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