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Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures
  1. S Hassan Akbari1,
  2. Matthew R Reynolds1,
  3. Yasha Kadkhodayan2,
  4. DeWitte T Cross III1,2,
  5. Christopher J Moran1,2
  1. 1Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA
  2. 2Department of Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri, USA
  1. Correspondence to Dr M R Reynolds, Barnes-Jewish Hospital, Department of Neurological Surgery, Campus Box 8057, 660 South Euclid Avenue, St. Louis, MO 63310, USA; reynoldsm{at}


Introduction Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine (eg, clopidogrel) prevents stent related thromboembolic events in cardiac patients and is frequently utilized during neurointerventional surgery. However, recent data suggest that many patients exhibit clopidogrel resistance. Prasugrel—a newer thienopyridine—lowers the rate of cardiac stent thromboses in clopidogrel non-responders but a paucity of data exist regarding its safety and efficacy in neurointerventional surgery.

Methods All patients undergoing neurointerventional surgery by a single interventionalist (CJM) over a 20 month period were retrospectively identified. Charts were reviewed for pre- and post-procedural DAPT regimens, pre-procedural coagulation parameters and procedural complications.

Results 76 patients received pre- and post-procedural DAPT for endovascular treatment of an intracerebral aneurysm, dural arteriovenous fistula or intra/extracranial arterial stenosis. 51 patients underwent 55 total procedures and were treated with aspirin/clopidogrel; 25 patients underwent 31 total procedures and were treated with aspirin/prasugrel. Those patients who received aspirin/prasugrel DAPT were identified pre-procedurally to be clopidogrel non-responders. Both treatment groups had a similar percentage of patients undergoing aneurysm coiling, stent assisted aneurysm coiling, aneurysm Onyx embolization, aneurysm pipeline embolization device treatment, extra/intracranial carotid artery angioplasty and stenting, and dural arteriovenous fistula coil embolization. A total of eight (9.3%) hemorrhagic complications were observed, two (3.6%) in the aspirin/clopidogrel group and six (19.4%) in the aspirin/prasugrel group (p=0.02). No differences were noted in hemorrhage rates for each procedure between treatment groups, nor were there any differences in thrombotic complications between groups.

Conclusion Our results suggest that DAPT with aspirin/prasugrel may predispose to a higher risk of hemorrhage during neurointerventional surgery compared with DAPT with aspirin/clopidogrel.

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  • SHA and MRR contributed equally to this work.

  • Competing interests None.

  • Ethics approval Ethics approval was provided by Washington University Medical School Human Research Protection Office.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement A synopsis of our original dataset is presented in the current paper. However, additional data, including explanatory material, complete data sets, etc, is available to fellow researchers on request.

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