Incidence of cerebral ischemic events after discontinuation of clopidogrel in patients with intracranial aneurysms treated with stent-assisted techniques Clinical article
Departments of Neurosurgery and. Journal of Neurosurgery
(Impact Factor: 3.74).
09/2012; 117(5). DOI: 10.3171/2012.8.JNS12185
The optimal antiplatelet medication protocol for prevention of thrombotic complications after stent-assisted coil embolization of cerebral aneurysms is unclear. Early cessation of antiplatelet agents may be associated with an increased risk of cerebral ischemic events. In this study, the authors assess the incidence of stroke or transient ischemic attack (TIA) following discontinuation of a 6-week course of clopidogrel in patients with cerebral aneurysms treated with stent-assisted techniques.
A retrospective review was conducted in all patients with cerebral aneurysms undergoing stent-assisted coil embolization or stent-in-stent flow diversion at the University of Iowa during a 24-month period. The antiplatelet protocol was 81 mg aspirin and 75 mg clopidogrel daily for 6 weeks, followed by 325 mg aspirin daily indefinitely. The incidence of stroke or TIA was determined by a retrospective review of medical records generated during a 3-month period following discontinuation of clopidogrel.
A total of 154 patients underwent aneurysm treatment with stent techniques during this interval. Documentation of neurological follow-up 3 months after discontinuation of a 6-week clopidogrel treatment was available in 121 (78.6%) of 154 patients. Of these 121 patients, 114 were treated with stent-assisted coil embolization and 7 with stent-in-stent flow diversion. Six patients (5%) suffered an ischemic event after cessation of clopidogrel, with 2 events occurring within the first 2 weeks. Specifically, the rate of ischemic events was 5 (4.3%) of 114 in the "stent-coil" treatment group and 1 (14.3%) of 7 in the stent-in-stent group. Treatment had been performed in the setting of a subarachnoid hemorrhage in 1 patient. Atypical aneurysm features and technical factors predisposing to thrombotic events were found in all but one of these patients. Similarly, cardiovascular risk factors were present in 5 of the 6 patients in whom ischemic events developed after clopidogrel discontinuation.
Clopidogrel discontinuation is associated with a 5% risk of ischemic events in patients treated with stent techniques. Any stroke related to clopidogrel discontinuation is avoidable, and longer treatment is therefore clearly necessary. Patients with cardiovascular risk factors, high-risk aneurysm features, and those undergoing stent-in-stent flow diversion might benefit the most from longer clopidogrel therapy.
Available from: Jacques Lara
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ABSTRACT: Resumen Objetivos: Determinar en forma retrospectiva los resultados clínicos y angiográficos así como la efectividad y complicaciones de esta técnica utilizando un micro stent autoexpandible modelo LVIS. Materiales y Métodos: Desde enero del 2012 hasta abril de 2013, 18 pacientes (5 de sexo masculino y 13 de sexo femenino) fueron seleccionados en base a las características anatómicas de los aneurismas cerebrales, para ser tratados con la técnica de stent LVIS para la reconstrucción endovascular aneurismática. Previa antiagregación y anticoagulación los tres días del procedimiento y con monitorización continua de los tiempos de coagulación. Resultados: Todos los pacientes fueron exitosamente embolizados, en 16 pacientes con coils asistido con stent LVIS, en 2 pacientes únicamente se utilizó únicamente el stent LVIS por cambios en la geometría vascular y resolución de los aneurismas, y 1 paciente presentaba una historia previa de clipaje de aneurisma cerebral, el mismo que se recanalizo y se rompió. En todos los pacientes se logró una oclusión total del aneurisma, no hubo complicaciones relacionadas con el procedimiento y los pacientes fueron mantenidos con doble terapia antiplaquetaria. Conclusión: La técnica utilizando el Stent LVIS demostró ser útil y efectiva con buenos resultados angiográficos y clínicos. Y en base a nuestros resultados podemos decir que la técnica con el stent LVIS es bastante prometedora y presenta ventajas en cuanto a la adaptabilidad, reconstrucción endovascular y desviación del flujo a diferencia de otros tipos de microstents actualmente disponibles. No hubo eventos adversos durante los procedimientos. Abstract Aim: To determine retrospectively the angiographic and clinical outcomes as the efectivity and complications of this technique using a micro stent self-expanding LVIS devic. Materials and Methods: From January 2012 to April 2013, 18 patients (5 male and 13 female) were selected, based on the anatomical characteristics of their intracranial aneurysms, to be treated with the technique using the LVIS stent device for their endovascular reconstruction of the aneurysms. Three days before to the procedure , the patients were treated with antiplatelet and anticoagulant therapy, and continuos monitoring of the coagulation common parameters. Results: All patients were successfully embolized, 16 patients were used coils assisted with the LVIS device, 2 patients was only necessary the LVIS stent by showing changes in the vascular geometry and showing resolutions of the cerebral aneurysms, and 1 patient with surgical history of aneurysm clipped who had a recanalization of the aneurysm and subsequent ruptura. All patients the cerebral aneurysm were successfully embolizated, there were no complications related to the procedures and the patients were maintained on dual-antiplatelet therapy. Conclusion: The technique with LVIS stent device probed to be Trabajo Original
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ABSTRACT: New anticoagulant and antiplatelet medications have been approved and are prescribed with increased frequency. Intracranial hemorrhage is associated with the use of these medications. Therefore, neurosurgeons need to be aware of these new medications, how they are different from their predecessors, and the strategies for the urgent reversal of their effects. Utilization of intraluminal stents by endovascular neurosurgeons has resulted in the need to have a thorough understanding of antiplatelet agents. Increased use of dabigatran, rivaroxaban, and apixaban as oral anticoagulants for the treatment of atrial fibrillation and acute deep venous thrombosis has increased despite the lack of known antidotes to these medications.
Neurosurgical FOCUS 05/2013; 34(5):E6. DOI:10.3171/2013.2.FOCUS1328 · 2.11 Impact Factor
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ABSTRACT: Stent-assisted coil embolization is effective for intracranial aneurysms, especially wide-necked aneurysms; however, the optimal antiplatelet regimens for ischemic events that develop after coil embolization have not yet been established. We aimed to determine the onset time of such postoperative ischemic events and the relationship between these events and antiplatelet therapy.
We performed coil embolization using a vascular reconstruction stent for 43 cases of intracranial aneurysms and evaluated the incidence of postoperative ischemic events in these cases.
Nine patients showed postoperative ischemic events during the follow-up period (13 ± 7 months). Two patients developed cerebral infarction within 24 hours. Five patients developed transient ischemic attack within 40 days while they were receiving dual antiplatelet therapy. In addition, 1 patient showed cerebral infarction 143 days postoperatively during single antiplatelet therapy, and a case of transient visual disturbance was reported 191 days postoperatively (49 days after antiplatelet therapy had been discontinued). We increased the number of antiplatelet agents in 4 of these patients. The other 5 patients were under strict observation with dual antiplatelet therapy. All these patients were shifted to single antiplatelet therapy 3-13 months postoperatively. No recurrence of ischemic events was noted.
Postoperative ischemic events are most likely to occur within 40 days postoperatively. For patients with postoperative ischemic events, additional ischemic events can be prevented by increasing the number of antiplatelet agents; subsequently, they can be shifted to single antiplatelet therapy after the risk of recurrence has decreased.
Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 08/2013; 23(4). DOI:10.1016/j.jstrokecerebrovasdis.2013.07.008 · 1.67 Impact Factor
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