The placement of cervical and intracranial stents requires the administration of antiplatelet drugs to prevent thromboembolic complications. Ticagrelor has emerged as the most widely used alternative in clopidogrel non-responders owing to its potent antiplatelet effects. Because ticagrelor does not require hepatic activation, many neurointerventionalists choose to forgo laboratory testing of platelet inhibition. In rare instances, patients may not achieve adequate platelet inhibition following ticagrelor administration. In this paper we review the mechanism of action of ticagrelor and its use in cerebrovascular procedures. We present two cases of ticagrelor non-responsiveness from two high-volume cerebrovascular centers, discuss their management, and propose an algorithm for managing ticagrelor non-responsiveness.
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Contributors All authors have made a significant contribution to the final manuscript including conception of the idea, acquisition of data and literature review, drafting of the manuscript, and review of the final draft. The authors agree to its publication upon final review.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests BH is a lead investigator of the CAPTIVA RCT trial. AstraZeneca is supporting the CAPTIVA trial by providing ticagrelor (https://www.nihstrokenet.org/docs/default-source/default-document-library/hoh-captiva-9-12-18-v3ef07f0d0c2c66f0f86baff000016a715.pdf?sfvrsn=0).
Provenance and peer review Not commissioned; externally peer reviewed.