Background Antiplatelet use is common during endovascular treatment of cerebral aneurysms as it prevents thromboembolic complications. P2Y12 receptor antagonist, Clopidogrel, as well as cyclooxygenase inhibitor, aspirin are used in combination for patients undergoing stent coiling or flow diversion. Periprocedural hemorrhage with the use of dual antiplatelets continues to be of significant concern and is reported to occur in 2–24% of patients undergoing endovascular occlusion of cerebral aneurysms. We have utilized dual antiplatelets (aspirin and clopidogrel) for all patients undergoing endovascular treatment of unruptured cerebral aneurysms. We aim to report the rate of periprocedural hemorrhage for patients undergoing endovascular treatment of unruptured aneurysms and its relation to platelet function analysis based upon aspirin and clopidogrel (P2Y12) assays performed preoperatively.
Methods We conducted a retrospective review of patients who underwent elective intracranial aneurysm coiling between January 2005 and August 2014. These patients were either placed on dual antiplatelet agents for 6 months in instances where stents were used or the clopidogrel was discontinued postoperatively and the aspirin continued indefinitely in cases of uneventful coil embolization. The primary outcome of interest was the occurrence of a clinically significant hemorrhagic event from the periprocedural time period up to 6 months post treatment. We also evaluated other risk factors which contributed to hemorrhagic complications in our population including the role of super therapeutic (aspirin VerifyNow <450 and clopidogrel related platelet inhibition >50%) platelet inhibition as measured with VerifyNow assays.
Results During the study period, 412 patients underwent elective aneurysm coiling and had been placed on dual antiplatelets. Among this population, 24 (2%) systemic hemorrhage events and 5 (1%) CNS hemorrhage events occurred. Super therapeutic platelet inhibition was present in 8 of the 24 patients with systemic hemorrhages and 2 of the 5 patients with central nervous system (CNS) hemorrhages (p = 0.68). Nine (2.2%) patients were identified as clopidogrel non responders and placed on prasugrel. Of these 9 patients one presented with systemic hemorrhage. In the 148 patients who had dual antiplatelet therapy continued for 6 months after placement of a stent, 10 patients had systemic hemorrhage events and 4 had CNS hemorrhage events. All five patients with CNS hemorrhage had a decline in clinical functioning with 2 patients at mRS 2 and three patients were deceased (mRS 6).
Conclusions Use of dual antiplatelets did not lead to a high incidence of hemorrhages and hemorrhagic complications were not related to super therapeutic platelet inhibition. Those patients with CNS hemorrhagic complications did have significant decline in clinical functioning.
Disclosures R. Shastri: None. A. Pandey: None. T. Wilson: None. W. Stetler: None. D. Giles: None. M. Davis: None. N. Chaudhary: None. J. Gemmete: None. B. Thompson: None.
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