Antiplatelets and antithrombotics in neurointerventional procedures: Guideline update

Abstract

BackgroundAntiplatelet and antithrombotic medication management before, during, and after neurointerventional procedures has significant practice variation. This document updates and builds upon the 2014 Society of NeuroInterventional Surgery (SNIS) Guideline ‘Platelet function inhibitor and platelet function testing in neurointerventional procedures’, providing updates based on the treatment of specific pathologies and for patients with specific comorbidities.MethodsWe performed a structured literature review of studies that have become available since the 2014 SNIS Guideline. We graded the quality of the evidence. Recommendations were arrived at through a consensus conference of the authors, then with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors.ResultsThe management of antiplatelet and antithrombotic agents before, during, and after endovascular neurointerventional procedures continues to evolve. The following recommendations were agreed on. (1) It is reasonable to resume anticoagulation after a neurointerventional procedure or major bleeding episode as soon as the thrombotic risk exceeds the bleeding risk in an individual patient (Class I, Level C-EO). (2) Platelet testing can be useful to guide local practice, and specific approaches to using the numbers demonstrate marked local variability (Class IIa, Level B-NR). (3) For patients without comorbidities undergoing brain aneurysm treatment, there are no additional considerations for medication choice beyond the thrombotic risks of the catheterization procedure and aneurysm treatment devices (Class IIa, Level B-NR). (4) For patients undergoing neurointerventional brain aneurysm treatment who have had cardiac stents placed within the last 6–12 months, dual antiplatelet therapy (DAPT) is recommended (Class I, Level B-NR). (5) For patients being evaluated for neurointeventional brain aneurysm treatment who had venous thrombosis more than 3 months prior, discontinuation of oral anticoagulation (OAC) or vitamin K antagonists should be considered as weighed against the risk of delaying aneurysm treatment. For venous thrombosis less than 3 months in the past, delay of the neurointerventional procedure should be considered. If this is not possible, see atrial fibrillation recommendations (Class IIb, Level C-LD). (6) For patients with atrial fibrillation receiving OAC and in need of a neurointerventional procedure, the duration of TAT (triple antiplatelet/anticoagulation therapy=OAC plus DAPT) should be kept as short as possible or avoided in favor of OAC plus single antiplatelet therapy (SAPT) based on the individual’s ischemic and bleeding risk profile (Class IIa, Level B-NR). (7) For patients with unruptured brain arteriovenous malformations there is no indication to change antiplatelet or anticoagulant management instituted for management of another disease (Class IIb, Level C-LD). (8) Patients with symptomatic intracranial atherosclerotic disease (ICAD) should continue DAPT following neurointerventional treatment for secondary stroke prevention (Class IIa, Level B-NR). (9) Following neurointerventional treatment for ICAD, DAPT should be continued for at least 3 months. In the absence of new stroke or transient ischemic attack symptoms, reversion to SAPT can be considered based on an individual patient’s risk of hemorrhage versus ischemia (Class IIb, Level C-LD). (10) Patients undergoing carotid artery stenting (CAS) should receive DAPT before and for at least 3 months following their procedure (Class IIa, Level B-R). (11) In patients undergoing CAS during emergent large vessel occlusion ischemic stroke treatment, it may be reasonable to administer a loading dose of intravenous or oral glycoprotein IIb/IIIa or P2Y12 inhibitor followed by maintenance intravenous infusion or oral dosing to prevent stent thrombosis whether or not the patient has received thrombolytic therapy (Class IIb, C-LD). (12) For patients with cerebral venous sinus thrombosis, anticoagulation with heparin is front-line therapy; endovascular therapy may be considered particularly in cases of clinical deterioration despite medical therapy (Class IIa, Level B-R).ConclusionsAlthough the quality of evidence is lower than for coronary interventions due to a lower number of patients and procedures, neurointerventional antiplatelet and antithrombotic management shares several themes. Prospective and randomized studies are needed to strengthen the data supporting these recommendations.

Perioperative complications of arteriovenous tirofiban administration versus oral dual antiplatelet therapy for stent‐assisted embolization treated aneurysmal subarachnoid hemorrhage: A retrospective, controlled cohort analysis

“…Tirofiban was initially used as antiplatelet therapy for acute ischemic stroke, which resulted in a better prognosis (Investigators et al., 2022 ; Zi et al., 2023 ). Furthermore, in accordance with the recent updates in guidelines about antiplatelet and antithrombotic agents in neurointervention, there is a consensus recommendation for the utilization of tirofiban in the context of stent‐assisted embolization for the prophylaxis of perioperative ischemic events in ruptured aneurysms(Schirmer et al., 2023 ). Thereafter, a research team proposed a perioperative antiplatelet protocol for the prevention of perioperative TEs with tirofiban by a 3‐min intravenous infusion at 8 mg/kg and a subsequent 24‐h intravenous infusion of 0.1 ug/kg/min.…”

What are community perspectives regarding brain- computer interfaces? A cross-sectional study of community-dwelling adults in the UK

“…As such, the risks associated are not clear, this underscores the necessity for monitoring the well-being of chronic implant patients, while also facilitating the assessment of long-term e cacy. Additionally, Intravascular implantation (34) carries a distinct set of risks which can result in a stroke or haemorrhage (31) and it is again not yet clear whether the risk of thrombosis is worrisome or whether patients may need to take antiplatelet/antithrombotic post-procedure as other neuro-interventional procedures (35). Furthermore, aesthetic concerns may in uence the decision whether to adopt a BCI device (36).…”

Duration of dual-antiplatelet therapy after stent-assisted coil for unruptured intracranial aneurysm: A nationwide cohort study

“…4 However, there are no large randomized control trials and evidence-based guidelines for the optimal duration of DAPT after SAC for UIA. 1,3,5 The optimal duration of DAPT after stent placement is mainly investigated in patients with coronary artery disease and differs according to both bleeding and thromboembolic risks. [7][8][9] Considering that patients with UIA treated with SAC do not have symptomatic atherosclerotic stenosis, and all the stents used for UIA are of bare metal, the optimal duration of DAPT for these patients might be 1-6 months, as is the recommended period in patients with stable coronary artery disease who are treated with bare-metal stents.…”

“…2 After intravascular stent implantation, dual-antiplatelet therapy (DAPT) has been primarily used to avoid thromboembolic complications. 4,5 Although the duration of poststent implantation DAPT is determined by thromboembolic and hemorrhagic risk, the optimal DAPT duration in patients with UIA treated with SAC remains unclear. 1,3,5,6 There have been few studies regarding how long physicians use DAPT in real clinical practice and the severity of the risk of ischemic stroke and hemorrhagic complication.…”

“…4,5 Although the duration of poststent implantation DAPT is determined by thromboembolic and hemorrhagic risk, the optimal DAPT duration in patients with UIA treated with SAC remains unclear. 1,3,5,6 There have been few studies regarding how long physicians use DAPT in real clinical practice and the severity of the risk of ischemic stroke and hemorrhagic complication. In patients with UIA treated with SAC, DAPT is usually maintained for >3-9 months empirically, based on the guidelines for coronary stents, expert opinions, and small retrospective analyses.…”