Prophylactic Antiplatelet Medication in Endovascular Treatment of Intracranial Aneurysms: Low-Dose Prasugrel versus Clopidogrel

Abstract

The prasugrel group showed more effective and consistent platelet inhibition. We may omit the antiplatelet response assay with the low-dose prasugrel premedication before the endovascular treatment of patients with unruptured aneurysms. Further study is required to determine whether there is benefit of this strategy regarding clinical outcome.

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 .…”

Comparison of Prasugrel and Clopidogrel Used as Antiplatelet Medication for Endovascular Treatment of Unruptured Intracranial Aneurysms: A Meta-Analysis

“…Overall, 682 unruptured aneurysms were treated endovascularly using PS (cases), whereas 672 unruptured aneurysms were treated endovascularly using CP (controls). Five studies compared treatment-related outcomes between the PS and the CP groups, [7][8][9][10]14 whereas 2 studies reported series of patients exclusively treated with PS. 12,13…”

“…In 4 studies, 8,13,14 the loading dose of PS was 20 mg 1 day before treatment; in one study 9 it was 30 mg 1 day before treatment; in 2 studies, 10,12 the loading dose was between 40 and 60 mg 1 day before treatment; and in 1 study, 7 60 mg of PS was associated with 325 mg of acetylsalicylic acid (ASA). In 3 studies, CP, 75 mg, was combined with ASA, 100 mg 7,9 or ASA, 325 mg 10 , 5 days before treatment, whereas CP, 300 mg, was used alone in 2 studies 8,14 5 days before the procedure.…”

“…The maintenance dose of PS was 5 mg/day in 3 studies, 8,13,14 5-10 mg/day in 2 studies, 9,12 and 10 mg/day in 2 studies. 7,10 The maintenance dose of AT in the CP group was CP, 75 mg/day, ϩ ASA, 75-100 mg/day, in 4 studies, [8][9][10]14 whereas in 1 study CP, 75 mg/day, was associated with ASA, 325 mg/day. 7 The VerifyNow P2Y12 assay (Accumetrics, San Diego, California) was used to test the platelet activity in all the reported studies (in 1 series, there were no data about the platelet function testing 10 ).…”