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Platelet function inhibitors and platelet function testing in neurointerventional procedures
  1. Chirag D Gandhi1,
  2. Ketan R Bulsara2,
  3. Johanna Fifi3,
  4. Tareq Kass-Hout1,
  5. Ryan A Grant4,
  6. Josser Delgado Almandoz5,
  7. Joey English6,
  8. Philip M Meyers7,
  9. Todd Abruzzo8,
  10. Charles J Prestigiacomo1,
  11. Ciaran James Powers9,
  12. Seon-Kyu Lee10,
  13. Barbara Albani11,
  14. Huy M Do12,
  15. Clifford J Eskey13,
  16. Athos Patsalides14,
  17. Steven Hetts15,
  18. M Shazam Hussain16,
  19. Sameer A Ansari17,
  20. Joshua A Hirsch18,
  21. Michael Kelly19,
  22. Peter Rasmussen20,
  23. William Mack21,
  24. G Lee Pride22,
  25. Michael J Alexander23,
  26. Mahesh V Jayaraman24,
  27. on behalf of the SNIS Standards and Guidelines Committee
  1. 1Rutgers University-New Jersey Medical School, Department of Neurosurgery, Newark, New Jersey, United States
  2. 2Yale University School of Medicine, Department of Neurosurgery, New Haven, Connecticut, United States
  3. 3St. Luke's Roosevelt Hospital Center, Hyman Newman Institute of Neurology and Neurosurgery New York, New York, United States
  4. 4Yale University School of Medicine, Department of Neurosurgery, New Haven, Connecticut, United States
  5. 5Abbott Northwestern Hospital, Department of Interventional Neuroradiology, Minneapolis, Minnesota, United States
  6. 6UCSF, Department of Neurology and Radiology, San Francisco, California, USA
  7. 7Columbia Presbyterian Hospital, Department of Neurointerventional Surgery, New York, New York, United States
  8. 8University of Cincinnati, Department of Neurosurgery, Cincinnati, Ohio, United States
  9. 9Wexner Medical Center, Department of Neurosurgery, Columbus, Ohio, United States
  10. 10The University of Chicago, Department of Radiology, Chicago, Illinois, United States
  11. 11Christiana Care Health Systems, Department of Neurointerventional Surgery, Newark, Delaware, United States
  12. 12Stanford University, Department of Neurosurgery and Radiology, Stanford, California, United States
  13. 13Dartmouth-Hitchcock Medical Center, Department of Radiology, Neurology and Neurosurgery, Lebanon, New Hampshire, United States
  14. 14New York Presbyterian Hospital, Weill Cornell Medical College, Department of Neurological Surgery, New York, New York, United States
  15. 15WUCSF, Department of Radiology, San Francisco, California, United States
  16. 16Cleveland Clinic, Cleveland Clinic Stroke Program, Cleveland Heights, Ohio, United States
  17. 17Northwestern University, Feinberg School of Medicine, Chicago, Illinois, United States
  18. 18Massachusetts General Hospital, NeuroEndovascular Program, Boston Massachusetts, United States
  19. 19Royal University Hospital, University of Saskatchewan, Department of Neurosurgery, Saskatoon, Saskatchewan, Canada
  20. 20Cleveland Clinic, Neurosurgery Department, Cleveland, Ohio, United States
  21. 21University of Southern California, Department of Neurosurgery, Los Angeles, California, United States
  22. 22UT Southwestern, Department of Neuroradiology, Dallas, Texas, United States
  23. 23Cedars-Sinai Medical Center, Department of Neurosurgery, Los Angeles, California, United States
  24. 24Warren Alpert School of Medical at Brown University, Rhode Island, United States
  1. Correspondence to Chirag D Gandhi, Department of Neurosurgery, Rutgers University-NJ Medical School, Newark, NJ, USA; gandhich@rutgers.edu

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Introduction

Over the past decade there has been a growing use of intracranial stents for the treatment of both ischemic and hemorrhagic cerebrovascular disease, including stents to assist in the remodeling of the neck of aneurysms as well as the use of flow diverting devices for aneurysm treatment. With this increase in stent usage has come a growing need for the neurointerventional (NI) community to understand the pharmacology of medications used for modifying platelet function, as well as the testing methodologies available. Platelet function testing in NI procedures remains controversial. While pre-procedural antiplatelet assays might lead to a reduced rate of thromboembolic complications, little evidence exists to support this as a standard of care practice. Despite the routine use of dual antiplatelet therapy (DAT) with aspirin and a P2Y12 receptor antagonist (such as clopidogrel, prasugrel, or ticagrelor) in most neuroembolization procedures necessitating intraluminal reconstruction devices, thromboembolic complications are still encountered.1–3 Moreover, DAT carries the risk of hemorrhagic complications, with intracerebral hemorrhage (ICH) being the most potentially devastating.4 ,5

Light transmission aggregometry (LTA) is the gold standard to test for platelet reactivity, but it is usually expensive and may not be easily obtainable at many centers. This has led to the development of point-of-care assays, such as the VerifyNow (Accumetrics, San Diego, California, USA), which correlates strongly with LTA and can reliably measure the degree of P2Y12 receptor inhibition.6–9 VerifyNow results are reported in P2Y12 reaction units (PRUs), with a lower PRU value corresponding to a higher level of P2Y12 receptor inhibition and, presumably, a lower probability of platelet aggregation, and a higher PRU value corresponding to a lower level of P2Y12 receptor inhibition and, hence, a higher chance of platelet activation and aggregation.

While aspirin resistance is perhaps less common, clopidogrel resistance may be more challenging as …

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