Introduction Acute intraprocedural flow diverter thrombosis is a challenging and poor prognostic event during intracranial aneurysm treatment. Intraprocedural flow diverter thrombosis in a case of brilianta resistance is a rare entity. Ticagrelor is a directly acting cyclopentyltriazolo-pyrimidine which does not require conversion into an active metabolite. It inhibits the P2Y12 receptors on platelets reversibly. Unlike clopidogrel and aspirin ,resistance to ticagrelor is rarely reported. Here we report a case of post coiling recurrent intracranial aneurysm treated with flow diverter, presented immediately with hemiplegia on extubation subsequently managed with intra arterial tirofiban.

Methods A 28 year male patient with history of ruptured left A1 ACA aneurysm presented with small aneurysm recurrence on check 6 months DSA. Patient taken for flow diverter treatment. Pre-procedurely patient was loaded with aspirin and brilianta 5 days prior to procedure. Flow diverter deployment was uneventful. Post procedure patient was extubated. After extubation patient was found to have hemiplegia and aphasia . Immediate check angiography done which showed instent thrombosis. Subsequently Intra arterial tirofiban bolus was given with reopening of flow diverter stent was obtained.

Results Hemiplegia improved immediately.

Patient discharged hemodynamically stable. Patient started with prasugrel 10mg once daily. Platelet function test showed ticagrelor resistance.

Conclusion Acute intraprocedural flow diverter thrombosis is a rare complication in ticagrelor loaded patient. Intra-arterial bolus followed by intravenous tirofiban infusion seems to be efficacious and safe for acute intraprocedural flow diverter thrombosis. This case shows importance of checking antiplatelet resistance in patient who are even taking brilianta.

Disclosure of Interest Nothing to disclose’.