Prasugrel versus clopidogrel in stent-assisted coil embolization of unruptured intracranial aneurysms

Abstract

<jats:sec><jats:title>Background</jats:title><jats:p> Thromboembolic complications are the main problem in stent-assisted coil embolization of unruptured intracranial aneurysms. The combination of aspirin and clopidogrel is generally used to decrease these complications, but some patients do not respond to clopidogrel and have a higher risk of stent thrombosis. In cardiology, clinical trials have shown that prasugrel reduced the incidence of ischaemic events in patients with acute coronary syndrome compared with clopidogrel but, according to several authors, prasugrel would produce an increased risk of cerebral haemorrhagic complications. </jats:p></jats:sec><jats:sec><jats:title>Objective</jats:title><jats:p> The purpose of this study was to determine whether prasugrel would be more effective than clopidogrel in reducing procedural events in patients with an unruptured aneurysm treated endovascularly with coils and stent. </jats:p></jats:sec><jats:sec><jats:title>Materials and methods</jats:title><jats:p> Two hundred consecutive patients with intracranial aneurysms were treated using coiling and stenting procedures. The first 100 patients were administered a dual antiplatelet of aspirin and clopidogrel, while the remaining 100 patients were administered a dual antiplatelet of aspirin and prasugrel. In each group data were collected on procedural and periprocedural haemorrhagic and ischaemic complications. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Aneurysmal occlusion and haemorrhagic complications rates were identical in both groups. The number of thromboembolic events observed in the two groups of our study did not differ significantly, but the prasugrel group included more wide-neck aneurysms and more flow-diverted stents. Moreover, complications in the prasugrel group were more benign, explaining the significant difference in clinical outcomes between the two groups on Day 30. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Prasugrel reduces the clinical consequences of thromboembolic complications of endovascular treatment with stenting and coiling of unruptured intracranial aneurysms. </jats:p></jats:sec>

Long-term follow-up of aneurysms treated electively with woven stent-assisted coiling

“…Sedat et al compared two cohorts, one treated with aspirin plus clopidogrel, and the other with aspirin plus prasugrel. Although the number of thromboembolic events did not differ statistically, clopidogrel appeared to be associated with three times more serious statistically significant thromboembolic events, such as complete stent thrombosis at 30 days30. Overall, our complication rate compares favourably with rates reported in the literature, with meta-analysis compiling total complication rates of 10.9–17.6%, with a 6.8–9.1% mortality rate, thromboembolic complication rate of 4.2%, and permanent complication rate of 3.8–5.6% recorded8.…”

Platelet Function Testing in Neurovascular Procedures: Tool or Gimmick?

“…Neither of these studies ( n = 136) adjusted the antiplatelet regime in the setting of proven clopidogrel resistance. Sedat et al [24] found similar rates of thromboembolic events when either clopidogrel or prasugrel was used. A study from Brinjikji et al [12] assessed neurologic morbidity and mortality in patients with and without PFT for clopidogrel resistance in NVS procedures.…”

Periprocedural Neuroendovascular Antiplatelet Strategies for Thrombosis Prevention in Clopidogrel‐Hyporesponsive Patients

“…Seven studies reported outcomes of patients undergoing neuroendovascular procedures managed on clopidogrel therapy compared with prasugrel therapy. 16,[22][23][24][25][26][27] Overall, prasugrel therapy in clopidogrel hyporesponders was associated with a similar rate of thrombotic complications compared with clopidogrel use in responders, with two of the seven comparative studies reporting a statistically significant decrease in thromboembolic complications. 26,27 Prasugrel also appeared to have similar rates of hemorrhagic complications, although one study 22 reported a higher rate of hemorrhagic complications compared with clopidogrel (19.4% vs 3.6%, p=0.02) in a heterogeneous population undergoing neuroendovascular procedures including stentassisted coiling (34.9%), aneurysm coiling (25.6%), PED placement (18.6%), extra-or intracranial carotid angioplasty and stenting (12.8%), onyx embolization (7%), and dural arteriovenous fistula coil embolization (1.2%).…”

“…Loading doses ranged from 20–60 mg, and maintenance doses ranged from 5–10 mg/day. Seven studies reported outcomes of patients undergoing neuroendovascular procedures managed on clopidogrel therapy compared with prasugrel therapy . Overall, prasugrel therapy in clopidogrel hyporesponders was associated with a similar rate of thrombotic complications compared with clopidogrel use in responders, with two of the seven comparative studies reporting a statistically significant decrease in thromboembolic complications .…”