Safety and Efficacy of Prasugrel with Endovascular Treatment for Unruptured Cerebral Aneurysm

Abstract

Objective: Recently, dual-antiplatelet therapy (DAPT) including clopidogrel (CLP) with endovascular treatment for unruptured cerebral aneurysm has been widely accepted. However, patients who are poor metabolizers of CLP (CLPPMs) are more frequent in East Asians than in Caucasians, and an adequate antiplatelet effect may not be achieved with a normal dose in such patients. Prasugrel, which is a novel thienopyridine antiplatelet drug that is less likely to be poorly metabolized than CLP, is used widely for percutaneous coronary intervention, but its efficacy and safety with neuroendovascular treatment have not been elucidated. From this point of view, the purpose of this study was to elucidate the safety and efficacy of prasugrel with endovascular treatment for unruptured cerebral aneurysm. Methods:We investigated 108 consecutive patients with an unruptured cerebral aneurysm who underwent endovascular treatment from March 2015 to January 2016 in our hospital. All patients received DAPT with 100 mg aspirin and 75 mg CLP daily, and antiplatelet function was evaluated by VerifyNow (Accumetrics, San Diego, CA, USA). In patients with P2Y12 reaction units (PRU) over 230, prasugrel was administered with a loading dose of 20 mg and a maintenance dose of 3.75 mg daily.Results: Prasugrel was administered to 12 patients in our series. Of these patients, the mean age was 63.1 ± 13.0 years, and the mean PRU was 272 ± 20. Eleven patients received endovascular treatment with intracranial stents, of which four patients received treatment with flow diverters. The mean observational period was 5-13 months (median: 6.5), and no symptomatic hemorrhagic and ischemic complications occurred. Mean PRU was decreased to 159 ± 63 in the six patients in which PRU were re-examined. Conclusion:Prasugrel is safe and effective with endovascular treatment for unruptured cerebral aneurysm in CLP-PMs.

Outcome of intracranial flow diversion according to the antiplatelet regimen used: a systematic review and meta-analysis

“…One study found that all patients were among the expected antiplatelet inhibition rate 33. The remaining studies did not report complications based on antiplatelet testing results, but 20 studies reported the action taken after abnormal results: two studies reported postponing procedures,34 35 three reported modification of the loading dose,36–38 eight reported switching to prasugrel/ticagrelor regimens,14 39–45 and seven studies reported switching to an alternative regimen 46–52. Another eight studies (335 patients) did not conduct antiplatelet testing at all and nine studies with 406 patients did not report the data on its usage (table 2).…”

The Usefulness of Prasugrel as Rescue Medication in Neuroendovascular Therapy

“… 19) A recent Japanese study reported that prasugrel (loading dose: 20 mg, maintenance dose: 3.75 mg) was safe and effective in PMs of clopidogrel with endovascular therapy for unruptured cerebral aneurysms. 5) Internationally, several studies stated that low-dose prasugrel (loading dose: 20 mg, maintenance dose: 5 mg) was useful for the treatment of cerebral aneurysms. 7 , 20) A meta-analysis of these studies also demonstrated that low-dose prasugrel reduced thrombosis, and that it did not increase the incidence of hemorrhagic complications.…”

“…Recent studies reported the safety and efficacy of prasugrel for clopidogrel resistance or thrombosis in patients undergoing neuroendovascular therapy. 5 – 7) Prasugrel resistance is rare, and the interval until its effects are observed is short. However, this drug has not been approved in the cerebrovascular field.…”