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Hemorrhagic stroke
Original research
Excessive platelet inhibition following Pipeline embolization of intracranial aneurysms
  1. Timothy R Miller1,
  2. Mihir Khunte2,
  3. Nicholas Caffes3,
  4. Megan Anders4,
  5. Peter Rock4,
  6. Amber L Beitelshees5,
  7. Ajay Malhotra2,
  8. Gregory Cannarsa3,
  9. Jacob Cherian3,
  10. J Marc Simard3,
  11. Gaurav Jindal1,
  12. Dheeraj Gandhi1
  1. 1 Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
  2. 2 Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
  3. 3 Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
  4. 4 Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
  5. 5 Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Timothy R Miller, Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; tmiller5{at}umm.edu

Abstract

Background High levels of platelet inhibition have been associated with hemorrhagic complications following Pipeline embolization of intracranial aneurysms. We therefore titrate clopidogrel dosing to maintain a moderate level of platelet inhibition using the VerifyNow P2Y12 assay. However, many patients demonstrate dramatic increases in platelet inhibition following treatment despite being on a consistent antiplatelet regimen. We therefore elected to explore the incidence of this phenomenon and possible predisposing factors.

Methods All successful Pipeline aneurysm treatments performed at our institution from 2011 to 2019 with moderate procedure-day platelet inhibition levels as indicated by a VerifyNow PRU of 60–235 were included. Patients who received glycoprotein IIb/IIIa inhibitors and those treated for ruptured/symptomatic lesions were excluded. The incidence of excessive platelet inhibition defined by a PRU<60 within 8 weeks of treatment was noted. Multivariable logistic regression was performed to determined independent predictors of the phenomenon.

Results Some 190 treatments were performed in 178 qualifying patients. A post-procedure PRU <60 occurred following 79% of treatments, documented on average after 8.5 (range 1–47) days. A higher procedure day hematocrit level (P=0.003, OR 1.09, 95% CI 1.029 to 1.152) was an independent predictor of reaching a PRU <60, while intra-procedural midazolam exposure (P=0.044, OR 0.44, 95% CI 0.201 to 0.980) and a higher procedure-day PRU (P=0.047, OR 0.99, 95% CI 0.982 to 1.000) were associated with a reduced odds. Time-since-procedure and hematocrit levels were associated with excessive platelet inhibition when excluding patients who initially demonstrated hyperresponse.

Conclusion Elevations in platelet inhibition were frequently observed following flow diversion with Pipeline.

  • aneurysm
  • flow diverter
  • hemorrhage
  • platelets

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/neurintsurg-2022-018858

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    Data availability statement

    Data are available upon reasonable request.

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    Footnotes

    • Twitter @AjayMalhotraRad

    • Contributors Conception or design of the work: TRM, GC, DG. Data collection: TRM, MK, MA, PR. Data analysis and interpretation: TRM, MK, NC, MA, AB. Drafting the article: TRM, MK, NC, DG. Critical revision of the article: all authors. Final approval of the version to be published: all authors. TRM is the guarantor of the current work.

    • 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 None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.