The Usefulness of Prasugrel as Rescue Medication in Neuroendovascular Therapy

Abstract

In neuroendovascular therapy, clopidogrel resistance and thrombosis are common problems. In such cases, we use prasugrel as rescue medication, and we clarified its usefulness. Methods: We retrospectively investigated 199 consecutive cases of neuroendovascular therapy performed at our hospital from April 2016 to March 2018, and examined the safety and effectiveness of prasugrel. Results: There were 14 cases of prasugrel administration: six cases of coil embolization for cerebral aneurysm, five cases of carotid artery stenting (CAS), and three other cases. The reasons for prasugrel administration were as follows: emergency stent use in four cases, intraoperative thrombosis in three cases, intra-stent thrombosis after CAS in three cases, and others in four cases. In all cases, it was used in combination with aspirin and the median duration of administration was 212 days. Regarding its safety, there was one hemorrhagic complication at the puncture site for which the involvement of prasugrel was unable to be excluded, but it was improved by conservative treatment and there was no major hemorrhage such as intracranial hemorrhage. Regarding its efficacy, in one case, the thrombus during coil embolization did not completely disappear after prasugrel administration and additional mechanical thrombolysis was required. However, no new thrombosis was observed during prasugrel administration in all 14 cases. Conclusion: Prasugrel may be useful as a rescue medication in neuroendovascular therapy. Keywords▶ neuroendovascular therapy, prasugrel, clopidogrel resistance, thrombosis, antiplatelet drug loading thrombosis. 1,2) To prevent thrombosis, dual antiplatelet drugs are administered before surgery in many cases. However, some stent-inserted patients require the long-term administration of antiplatelet drugs after surgery, and hemorrhagic complications must be considered. 1,2) Therefore, perioperative antiplatelet drug management in neuroendovascular therapy is important. As antiplatelet drugs, aspirin and clopidogrel are routinely used. However, the latter raises the issue of resistance. Several studies demonstrated that the incidence of thromboembolism during coil embolization of cerebral aneurysms increased in the presence of clopidogrel resistance. 3,4) Furthermore, prompt, accurate intraoperative antiplatelet drug loading is required in some emergency cases free from antiplatelet drug administration. 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. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.