Table 4

Antiplatelet and anticoagulation management for selected neurointerventional treatment procedures

Unruptured aneurysm*Ruptured aneurysm†Unruptured AVM‡Ruptured AVM§ICAD¶CAS**
No comorbiditiesNone, SAPT or DAPT††None, SAPT, or DAPTNone or SAPTNoneDAPTDAPT
Coronary stent/PCIDAPTSAPT if ≥3–6 months post PCI.
DAPT if <3–6 months post PCI
DAPTSAPT if ≥3–6 months post PCI.
DAPT if <3–6 months post PCI
DAPTDAPT
Atrial fibrillationAC+SAPT or AC+DAPT, reassess risk at 3 monthsSAPT, reassess risk at 1 monthAC+SAPT or AC+DAPT, reassess risk at 3 monthsSAPT, reassess risk at 1 monthAC+SAPT or AC+DAPT, reassess risk at 3 monthsAC+SAPT or AC+DAPT, reassess risk at 3 months
Acute systemic venous thrombosisAC+SAPT or AC+DAPT, reassess risk at 3 monthsSAPT,
consider IVC filter, reassess risk at 1 month
AC+SAPT or AC+DAPT, reassess risk at 3 monthsSAPT,
consider IVC filter, reassess risk at 1 month
AC+SAPT or AC+DAPT, reassess risk at 3 monthsAC+SAPT or AC+DAPT, reassess risk at 3 months
  • How to use this table: These recommendations are not exhaustive but instead are meant as a general approach. Medications need to be individualized to a particular patient using multidisciplinary management.

  • *Unruptured aneurysm (or ruptured aneurysm ≥14 days after rupture)—including coiling (SAPT), balloon-assisted coiling (SAPT), stent-assisted coiling (DAPT), flow-diverting stent (DAPT), intra-saccular flow disruption (DAPT).

  • †Ruptured aneurysm (<14 days after rupture)—including coiling (none), balloon-assisted coiling (none), stent-assisted coiling (procedural IV DAPT converted to oral DAPT within 24 hours**), flow-diverting stent (procedural IV DAPT converted to oral DAPT within 24 hours**), intrasaccular flow disruption (none or SAPT**). Note that open surgery may be preferable to endovascular therapy for aneurysms amenable to surgical therapy given the complexity of antiplatelet management in patients with ruptured aneurysms who may also need extraventricular drain placement.

  • ‡Unruptured AVM—including transarterial or transvenous n-BCA, EVOH, or coil embolization.

  • §Ruptured AVM—including transarterial or transvenous n-BCA, EVOH, or coil embolization.

  • ¶Intracranial atherosclerotic disease (ICAD)—including angioplasty and/or stenting.

  • **Carotid artery stenting (CAS)—including angioplasty and stenting.

  • ††See also 2014 SNIS Guideline

  • ‡‡Ospel et al, 202098

  • AC, anticoagulation; AVM, arteriovenous malformation; DAPT, dual antiplatelet therapy (usually aspirin plus another agent); EVOH, ethylene vinyl alcohol copolymer; IV, intravenous; IVC, inferior vena cava; n-BCA, n-butyl cyanoacrylate ; PCI, percutaneous coronary intervention; SAPT, single antiplatelet therapy (usually aspirin monotherapy).