Acute stent thrombosis after stent-assisted coiling in an intracranial aneurysm patient carrying two reduced-function CYP2C19 alleles

Abstract

Rationale:Stent thrombosis (ST) remains a thorny issue in spite of dual antiplatelet treatment with aspirin plus clopidogrel after stent-assisted coiling (SAC). We report a first case of acute ST after SAC in an intracranial aneurysm (IA) patient who carries two reduced-function CYP2C19 alleles.Patient concerns:A 43-year-old Chinese male carrying two reduced-function CYP2C19 alleles was treated with a loading dose of clopidogrel 300 mg and aspirin 300 mg before SAC. Unfortunately, life-threatening ST appeared 0.5 h later after SAC.Interventions:A total of 100000U of urokinase was used to dissolve ST. Meanwhile, tirofiban and nodroparin was also administrated to prevent recurrent thrombotic events.Outcomes:A repeated angiography demonstrated a successful reperfusion after thrombolytic treatment.Lessons:The present case demonstrates that CYP2C19 allele carriers may lead to a suppressed antiplatelet effect of clopidogrel and a high risk of ST in the meantime. Therefore, CYP2C19 genetic testing seems to be able to identify patients-at-risk and optimal antiplatelet treatment should be considered in these fragile populations.

Unique Indications for Covered Stent Grafts in Neuroradiology Departments of Level 1 Trauma Centers

“…In order to treat in-stent thrombosis drugs like tirofiban and abciximab have proven their efficiency in clinical practice in small patient populations with acute in-stent thrombosis of flow diverters, carotid artery stents, and intracranial stents. [36][37][38] Further studies could evaluate if these drugs should be administered before in-stent thrombosis occurs in emergency patients who could not be premedicated but have no eminent bleeding risk.…”

“…Even though IV heparin dissolved in-stent thrombosis, current literature indicates that glycoprotein IIb/IIIa inhibitors are very efficient and safe drugs for treatment of in-stent thrombosis in neuroradiologic cases. [36][37][38] The patient of case 4 developed in-stent thrombosis during intervention. In this case we have to point out that two GraftMaster stents and one Pipeline flow diverter had to be used and overlapped in the left ICA of this patient, immensely increasing the thrombogenicity.…”

Efficacy and safety of CYP2C19 genotype in stroke or transient ischemic attack patients treated with clopidogrel monotherapy or clopidogrel plus aspirin

“…Of the reduced-function alleles, CYP2C19∗2 is the most frequent variant which accounts for more than 95% of the reduced-function allele carrier status in white and black African populations and for more than 75% in Asian populations. [ 14 , 15 ] Thus, studies will be eligible if they are genotyped at least the CYP2C19∗2.…”