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• The Ongoing Debate Over Dual Antiplatelet Therapy in Cerebral Aneurysm Treatment
  Ali Mirshamsi
  Published on: 12 January 2024

• Published on: 12 January 2024

  The Ongoing Debate Over Dual Antiplatelet Therapy in Cerebral Aneurysm Treatment

  • Ali Mirshamsi, MD Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran

  Dear Editor,
  I am writing to address the significant findings presented in the article "Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE)." This research, a randomized clinical trial aimed at unraveling the ideal duration of Dual AntiPlatelet Therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysms, raises crucial questions regarding the management of these delicate cases.
  The article reports that the trial, DAPTS ACE, investigated whether extending DAPT for 12 months could effectively reduce the risk of ischemic stroke in comparison to a shorter 3-month DAPT regimen for patients who underwent SACE for cerebral aneurysms. The study, conducted in 17 hospitals in Japan, enrolled 142 patients between November 4, 2016, and January 7, 2019, and assigned them randomly to either the long-term or short-term DAPT group. The primary outcome was the occurrence of ischemic stroke events during the period of 3 to 12 months after SACE.
  The results are undeniably important, as they indicate that there was no statistically significant difference in the rate of ischemic strokes between the long-term and short-term DAPT groups. In fact, ischemic stroke was a rare occurrence in both groups, and the data show that the extended duration of DAPT did not offer a significant advantage in preventing ischemic events. This is the first randomized controlled trial to tackle the duratio...

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  Dear Editor,
  I am writing to address the significant findings presented in the article "Short- versus long-term Dual AntiPlatelet Therapy for Stent-Assisted treatment of CErebral aneurysm (DAPTS ACE)." This research, a randomized clinical trial aimed at unraveling the ideal duration of Dual AntiPlatelet Therapy (DAPT) after stent-assisted coil embolization (SACE) for cerebral aneurysms, raises crucial questions regarding the management of these delicate cases.
  The article reports that the trial, DAPTS ACE, investigated whether extending DAPT for 12 months could effectively reduce the risk of ischemic stroke in comparison to a shorter 3-month DAPT regimen for patients who underwent SACE for cerebral aneurysms. The study, conducted in 17 hospitals in Japan, enrolled 142 patients between November 4, 2016, and January 7, 2019, and assigned them randomly to either the long-term or short-term DAPT group. The primary outcome was the occurrence of ischemic stroke events during the period of 3 to 12 months after SACE.
  The results are undeniably important, as they indicate that there was no statistically significant difference in the rate of ischemic strokes between the long-term and short-term DAPT groups. In fact, ischemic stroke was a rare occurrence in both groups, and the data show that the extended duration of DAPT did not offer a significant advantage in preventing ischemic events. This is the first randomized controlled trial to tackle the duration of DAPT following SACE for intracranial aneurysms.
  The study's findings underscore a critical point of discussion among neurointerventionalists. With the expanded use of stents for treating cerebral aneurysms, the challenge of thromboembolic complications has come to the forefront. While DAPT, combining aspirin and clopidogrel, is considered a standard regimen post-SACE, the optimal duration has remained a matter of conjecture. Various studies have explored different timeframes, from 3 months to 6 months to 9 months or more, with varying conclusions. The debate extends to the potential hemorrhagic complications associated with DAPT.
  The DAPTS ACE trial brings us one step closer to addressing these uncertainties. One of the reasons cited for the lack of significant differences in outcomes is the diminishing rate of delayed thromboembolic events after SACE, largely due to advancements in stent technology. As the study indicates, the event rate was low and similar between the randomized and non-randomized cohorts, implying that the choice of enrollment may not significantly affect the results.
  Moreover, the discussion delves into the importance of individualized patient therapy, particularly in terms of platelet function testing. The study highlights the significance of understanding individual variations, especially in response to clopidogrel, which is affected by genetic polymorphism. Therefore, platelet aggregation testing plays a crucial role in optimizing patient care.
  While this trial offers invaluable insights, it's essential to acknowledge its limitations. The small sample size and the number of patients who achieved the primary endpoint were lower than expected. Larger studies are warranted to delve deeper into the benefits of long-term DAPT after SACE. Furthermore, the post-procedure timing of registration could have introduced some selection bias, as high-risk cases might have been avoided. However, it's noteworthy that the event rate in the non-randomized cohort was also low.
  In conclusion, the DAPTS ACE trial represents a significant step in the quest to determine the ideal duration of DAPT following SACE for cerebral aneurysms. While it doesn't provide a clear verdict, it contributes significantly to the ongoing discussion in the field. The implications are not only relevant for neurointerventionalists but also for the patients who depend on these treatments. As we await further studies with larger cohorts, this research sheds light on the complexity of patient care in the realm of cerebral aneurysm treatment.

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  Conflict of Interest:
  None declared.

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