Case reportIntracerebral hemorrhage after pipeline embolization: Management of antiplatelet agents and the case for point-of-care testing—Case reports and review of literature
Introduction
The pipeline embolization device (PED) has emerged as a highly efficient treatment modality for a wide range of intracranial aneurysms [3], [4], [5], [10], [14], [17], [18], [19], [27]. In contrast to conventional endovascular techniques, the PED provides a more physiologic approach in the treatment of intracranial aneurysms through a combination of flow diversion and endoluminal vessel reconstruction. The PED has been shown to be safe and effective in several large recent studies [1], [10], [14], [15], [18], [19], [24], [28]. One concern with PED therapy, however, is the risk of distal intracerebral hemorrhage (ICH) [8]. This poorly understood complication occurs not uncommonly following flow diversion (1–2% of the cases) and its management is difficult since complete reversal of antiplatelet agents could result in stent thrombosis while continuing the antiplatelet agents could facilitate hemorrhage expansion.
At our institution, we have recently implemented a new protocol for management of patients taking clopidogrel who present with spontaneous intraparenchymal hemorrhage and a low P2Y12 reaction units value (PRU). This protocol is used to guide platelet transfusion and antiplatelet therapy in these patients. Specifically, the goal of therapy is to maintain the PRU between 100 and 200. When the PRU is <100 on presentation, clopidogrel is discontinued and platelets are transfused. P2Y12 testing is performed initially every 6 h until the PRU is back above 100. As soon as the PRU is in the target window, platelet transfusion is stopped and clopidogrel is restarted. Serial testing is performed at least every 12 h after clopidogrel is restarted to monitor the platelet response, and the dose of clopidogrel is readjusted to maintain the PRU between 100 and 200. The patient is closely monitored in the neurointensive care unit and 3 repeat head CTs are obtained to rule out ICH expansion (in the absence of neurological deterioration). The patient undergoes weekly P2Y12 tests thereafter to ascertain that the level of platelet inhibition is in the 100–200 window.
In this paper, we present the case of 2 patients on aspirin and clopidogrel with post-PED ICH in whom this novel algorithm based on point-of-care platelet testing was used to guide blood product transfusion and antiplatelet therapy.
Section snippets
Case 1
This is a middle-aged patient who had an 8 mm right cavernous sinus aneurysm found incidentally following a motor vehicle accident. The aneurysm grew to 12 mm over a 2-year period. The patient underwent treatment with 3 overlapping PEDs (baseline PRU of 55), and the post-operative course was uneventful. The patient was re-admitted 1 week later due to right-sided orbital pain and headache, both of which rapidly resolved with a short course of steroids. MRI/MRA of the head demonstrated no residual
Discussion
Patients’ response to clopidogrel can be very variable. Qureshi et al. [22] reported that 21% of patients undergoing neurovascular procedures were resistant to clopidogrel while Fifi et al. [13] found the proportion of nonresponders to be as high as 36.5%. The presence of the allele CYP2C19*2 is associated with a diminished platelet response to clopidogrel and an increased risk for stent thrombosis and acute coronary syndrome [25].
Platelets take 3–5 days to recover their function after
Conclusions
We propose and preliminarily demonstrate the feasibility of a novel algorithm based on point-of-care platelet testing for guiding clopidogrel therapy and platelet transfusion. We hope that this algorithm will lead to better management of post-PED ICH and that this work will be built upon to provide clinicians with evidence-based guidelines for the management of these difficult situations.
Acknowledgements
None
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