Antiplatelet Therapy in Neurointervention

Alice Ma; Harshil Dharamdasani Detaram; Brendan Steinfort; Tim Harrington; Thanh N. Nguyen; Mohamad Abdalkader; George Siopis; Philip M. Bath; Permesh Singh Dhillon; Anna Podlasek; Adnan I. Qureshi; Zhongming Qiu; Kailash Krishnan

doi:10.1055/s-0043-1771383

Seminars in Neurology, Table of Contents

Semin Neurol 2023; 43(03): 466-479
DOI: 10.1055/s-0043-1771383

Review Article

Antiplatelet Therapy in Neurointervention

Alice Ma

¹Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia

,

Harshil Dharamdasani Detaram

¹Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia

,

Brendan Steinfort

¹Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia

,

Tim Harrington

¹Department of Neurosurgery, Royal North Shore Hospital, St. Leonards, New South Wales, Australia

,

Thanh N. Nguyen

²Department of Radiology, Boston Medical Centre, Boston, Massachusetts

,

Mohamad Abdalkader

²Department of Radiology, Boston Medical Centre, Boston, Massachusetts

,

George Siopis

³Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia

,

Philip M. Bath

⁴Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom

⁵Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

,

Permesh Singh Dhillon

⁶Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

⁷TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom

,

Anna Podlasek

⁶Department of Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

⁷TIME, Imaging Science and Technology, University of Dundee, Dundee, Scotland, United Kingdom

,

Adnan I. Qureshi

⁸Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri

,

Zhongming Qiu

⁹Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, People's Republic of China

,

Kailash Krishnan

⁴Stroke Trials Unit, University of Nottingham, Nottingham, United Kingdom

⁵Stroke, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom

› Author Affiliations

Abstract

The aim of this review is to provide an overview of the use of antiplatelet medication in neurointervention, with a focus on the clinical indications for antiplatelet use in both preventing and reducing platelet aggregation. This review will cover current antiplatelet medications, pharmacokinetics, and pharmacodynamics. We will provide an overview of different endovascular devices and discuss the antiplatelet regimes in neurointervention, highlighting gaps in evidence and scope for future studies.

Two randomized controlled trials have evaluated antiplatelet use in the setting of acute large vessel occlusion stroke, with neither demonstrating benefit in their overall cohorts. Evidence on antiplatelet medication for both acute and elective stenting for acute stroke and treatment of cerebral aneurysms is currently based on large case series, and practice in neurointervention has increasingly utilized dual antiplatelet regimes with clopidogrel and second-line agents like prasugrel and ticagrelor. Clopidogrel function testing has an increasing role in neurointerventional procedures, particularly for high metal surface area stents such as the braided flow diverter type stents. Intravenous glycoprotein IIB/IIIA inhibitors have been utilized for both acute bridging and rescue therapy.

Antiplatelet decision making is complex, and there are few randomized control trials to guide clinical practice. Comparative trials to guide decision making remain important in both the acute and elective settings. Standardised protocols incorporating platelet function testing may play a role in assisting decision making until more robust clinical evidence is available, particularly in the context of acute neurointerventional stenting for stroke and ruptured cerebral aneurysms.

Keywords

antiplatelet therapy - intracranial stenting - carotid stenting - stroke - aneurysms - mechanical thrombectomy

Full Text

References

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Supplementary Material

Supplementary Material