Delayed Clopidogrel Hyper-response after Neuroendovascular Therapy Associated with Hemorrhagic Complications

Endo, Hirahito; Kataoka, Taketo; Ogino, T.; Takahira, Kazuki; Yamaguchi, Yohei; Shindo, Koichiro; Maruga, Yohei; Kamiyama, Kenji; Osato, Toshiaki; Nakamura, Hirohiko

doi:10.5797/jnet.oa.2017-0004

Cited by 3 publications

(3 citation statements)

References 16 publications

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“…The prognosis, particularly in CAS cases, tends to be unfavorable. The perioperative administration of multiple antiplatelet agents and anticoagulants may exacerbate post-bleeding outcomes in CAS procedures, as has been reported with increased hemorrhagic complications due to clopidogrel hyper-response [ 4 ]. Concerning the timing of bleeding, occurrences post-CEA typically present later, suggesting a potential association with hyperperfusion syndrome.…”

Section: Discussionmentioning

confidence: 99%

“…Regarding treatment and prognosis, the patient in this report received strict blood pressure management, leading to favorable outcomes. Previous reports have documented cases of transient neurological deficits even in the presence of cortical SAH [ 4 ], underscoring the necessity for blood pressure control as in the case of cerebral hyperperfusion syndrome when hemorrhage is detected.…”

Section: Discussionmentioning

confidence: 99%

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Focal Non-aneurysmal Subarachnoid Hemorrhage After Carotid Artery Stenting: A Case Report

Tsuboki,

Mizuno

2024

Cureus

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Minor non-aneurysmal subarachnoid hemorrhage (SAH) following carotid artery stenting (CAS) is exceedingly rare and less described, with its underlying mechanism elusive. Here, we present the case of a 75-year-old female who underwent CAS for progressive asymptomatic severe stenosis of the internal carotid artery. Her post-procedural course remained uneventful, with no intracranial hemorrhage detected on the following day's magnetic resonance imaging (MRI). However, a routine MRI on the seventh post-procedural day identified a small amount of SAH in the central sulcus on the operative side. In the absence of symptoms, the patient was discharged home after a computed tomography (CT) scan revealed no signs of hemorrhagic enlargement the following day. In this report, we document the rare occurrence of localized SAH post-CAS. There are limited reports of minor SAH following CAS, with the underlying mechanisms remaining unclear. In this report, the localization of SAH aligns with the most critical ischemic sites, indicating that the mechanism of focal SAH after CAS is associated with blood-brain barrier (BBB) disruption due to a rapid increase in blood flow to small vessels with impaired vascular autoregulation. Focal convexity SAH is an easily overlooked finding, and the medical team performing carotid artery revascularization procedures should be aware of the potential for such SAH postoperatively and exercise caution during postoperative imaging interpretation.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Focal Non-aneurysmal Subarachnoid Hemorrhage After Carotid Artery Stenting: A Case Report

Tsuboki,

Mizuno

2024

Cureus

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“…In a study of Delgado Almandoz et al, 23) 59% of PRU normo-responders were later converted to hyper-responders. Furthermore, Endo et al 24) showed that continuation of dual-antiplatelet therapy consisting of aspirin and clopidogrel induced delayed clopidogrel hyper-response and was associated with postoperative hemorrhagic complications. Therefore, excessive inhibition should be avoided to prevent hemorrhagic complications.…”

Section: Discussionmentioning

confidence: 99%

Efficacy of Monitoring for Multiple Antiplatelet Therapy during Intracranial Stent Placement: A Preliminary Study

Suga

Oishi

Yamamoto

et al. 2021

JNET

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During cerebral aneurysm embolization using intracranial stents, platelet aggregation increases owing to increased wall shear stress and a loss of vascular endothelial function at the stent implantation site. Preoperative multiple antiplatelet therapy was introduced to prevent severe thromboembolic complications due to increased platelet aggregation. However, specific guidelines for the administration and pharmacological evaluation of this therapy do not exist currently. We examined the benefits of perioperative platelet aggregation monitoring in a cohort of patients. Methods:We had 377 patients with unruptured intracranial aneurysms who underwent stent-assisted embolization at our hospital between December 2012 and November 2019. We ultimately included 181 patients in our final analysis. These patients were continuously administered aspirin (100 mg/day) and clopidogrel (75 mg/day) for more than 5 days before the procedure to the post-procedural period. Of these patients, 30 patients who underwent light transmission aggregometry (LTA) before procedure, post-procedure (3 days after procedure), and at first post-discharge clinic visit were included as the subjects. The following characteristics were studied: age; sex; presence/absence of hypertension, dyslipidemia, and/or diabetes mellitus; location of aneurysm; type/number of stent; technique for stent placement; duration of preoperative multiple antiplatelet therapy; perioperative platelet aggregation test results; and postoperative ischemic or hemorrhagic complications.Results: Among these 30 patients, the median duration of antiplatelet therapy prior to the preoperative platelet aggregation measurements was 7 (interquartile range [IQR]: 6-8) days, and post-discharge measurement of LTA was performed at a median period of 27 (IQR: 22-35.5) days after procedure. The preoperative, postoperative, and first post-discharge clinic visit LTA values for adenosine diphosphate (ADP)-induced platelet aggregation were 50% (IQR: 44-54%), 42.5% (IQR: 36-48%), and 36% (IQR: 32-40%), respectively. These results represented gradual decrease in LTA values and a significant difference between the preoperative and post-discharge values. The LTA values for collagen aggregation showed a significant difference evident between the preoperative and post-discharge values; preoperative 38% (IQR: 27-60%), postoperative 42% (IQR: 30-58%), post-discharge 28% (IQR: 20-42%), respectively. We had one thromboembolic complication and one hemorrhagic complication. The results indicated that appropriate platelet aggregation monitoring during multiple antiplatelet therapy prevents thromboembolic complications such as stent thrombosis. However, we also found that many patients demonstrated increased postoperative platelet aggregation inhibitory effects due to the postoperative continuation of the same multiple antiplatelet therapy that was used preoperatively. Conclusion:This study demonstrates that postoperative, continuous, oral antiplatelet therapy induces increased platelet aggregation inhibition ...

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Periprocedural antiplatelet medication assessed by VerifyNow for neuroendovascular treatment: Comparison of prasugrel with clopidogrel

Nambu,

Misaki,

Uno

et al. 2023

Interv Neuroradiol

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Objective The maintenance dose of prasugrel (PRAS) for neuroendovascular treatment requires much research. We report the antiplatelet effect of PRAS measured by VerifyNow P2Y12 reaction units (PRUs) in patients during the perioperative period of neuroendovascular treatment. Methods Between January 2017 and January 2023, 230 patients who underwent endovascular treatment for unruptured intracranial aneurysms or carotid artery stenosis at our institution were retrospectively identified. Patients received dual antiplatelet therapy with 100 mg aspirin (ASA) and 75 mg clopidogrel (CLP)/day (CLP group, n = 186) or 100 mg ASA and 3.75 mg PRAS/day (PRAS group, n = 44) 2 weeks before the procedures. The PRU value was compared between the CLP and PRAS groups. In the study, we defined 95≦PRU < 208 as the optimal range. Perioperative complications within seven days of surgery were also analyzed. Results The mean value of PRU was significantly low in the PRAS group (179.13 ± 66.03 in CLP vs. 154.75 ± 54.01 in PRAS, p = 0.024). The proportion of the patients who exhibited 95≦PRU < 208 was significantly higher in the PRAS group (55.4% vs. 72.7%, p = 0.036). Ischemic and hemorrhagic complication rates were not significantly different between the CLP and PRAS groups (7.6% vs. 0%, p = 0.076; 4.7% vs. 0%, p = 0.361). The ischemic complication rate was higher in patients with a PRU > 208 than in those with PRU < 208 (12.5% vs. 3.8%, p = 0.044). The hemorrhagic complication rate was not significantly different between the PRU < 95 and 95≦PRU groups (8.4% vs. 3.2%, p = 0.224). Conclusions Maintenance dose PRAS further decreased the PRU value and reached the optimal range in more cases than CLP during the perioperative period of neuroendovascular treatment. Ischemic complications significantly increased in the 208 < PRU group.

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Delayed Clopidogrel Hyper-response after Neuroendovascular Therapy Associated with Hemorrhagic Complications

Cited by 3 publications

References 16 publications

Focal Non-aneurysmal Subarachnoid Hemorrhage After Carotid Artery Stenting: A Case Report

Focal Non-aneurysmal Subarachnoid Hemorrhage After Carotid Artery Stenting: A Case Report

Efficacy of Monitoring for Multiple Antiplatelet Therapy during Intracranial Stent Placement: A Preliminary Study

Periprocedural antiplatelet medication assessed by VerifyNow for neuroendovascular treatment: Comparison of prasugrel with clopidogrel

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