Background Thromboembolic complications continue to be encountered with PED despite the routine clopidogrel/aspirin anti-platelet therapy. Our study examined the safety and the efficacy of prasugrel and ticagrelor in the management of clopidogrel resistant patients treated for cerebral aneurysms.

Methods 437 consecutive patients were identified between January 2011 and May 2016. Patients allergic or having and it30% platelet-inhibition with a daily 75 mg of clopidogrel received 10 mg of prasugrel daily (n=20) or 90 mg of ticagrelor twice daily (n=2). The mean follow-up was 15.8 months (SD=12.4 months). The primary outcome was the modified Rankin Scale (mRS) registered before the discharge and at each follow-up visit. To control confounding we used multivariable mixed-effects logistic regression and propensity score conditioning.

Results Of 437 patients (mean of age 56.3 years; 62women [14,2%]), 26 (5.9%) presented with an acute sub-arachnoid hemorrhage. 7 patients were lost to follow-up (1 from the prasugrel group). 1 patient was reported allergic to clopidogrel and prasugrel. All the 22 patients receiving prasugrel had a mRS&It=2 on their latest follow-up visit (mean=0.67; SD=1.15). In a multivariate analysis, clopidogrel did not affect the mRS on last follow-up, p=0.14. Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (odds ratio[OR], 0.17; 95%confidence interval [CI95%], 0.01–2.70; p=0.21) neither with an increased thromboembolic accident rate (OR, 0.46; CI95%, 0.12–1.67; p=0.36) nor with an increased hemorrhagic event rate (OR, 0.39; CI95%,0.91–1.64; p=0.20). None of the patients receiving prasugrel deceased or had a long-term recurrence neither a hemorrhagic event, only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. 3 patients on clopidogrel deceased during the study: (2)from acute SAH and (1)from intra-parenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR, 2.18; CI95%, 0.11–43.27; p=0.61). The same associations were present in propensity score adjusted models.

Conclusion In a cohort of patients treated with PED, prasugrel (10 mg/day) and ticagrelor (90 mg twice/day) are safe alternatives to clopidogrel resistant, allergic or non-responders.

Disclosures E. Atallah: None. K. Bekelis: None. S. Tjoumakaris: None. R. Rosenwasser: None. P. Jabbour: None.