Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures

Abstract

Introduction: Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine (eg, clopidogrel) prevents stent related thromboembolic events in cardiac patients and is frequently utilized during neurointerventional surgery. However, recent data suggest that many patients exhibit clopidogrel resistance. Prasugrel-a newer thienopyridine-lowers the rate of cardiac stent thromboses in clopidogrel non-responders but a paucity of data exist regarding its safety and efficacy in neurointerventional surgery.

Methods: All patients undergoing neurointerventional surgery by a single interventionalist (CJM) over a 20 month period were retrospectively identified. Charts were reviewed for pre- and post-procedural DAPT regimens, pre-procedural coagulation parameters and procedural complications.

Results: 76 patients received pre- and post-procedural DAPT for endovascular treatment of an intracerebral aneurysm, dural arteriovenous fistula or intra/extracranial arterial stenosis. 51 patients underwent 55 total procedures and were treated with aspirin/clopidogrel; 25 patients underwent 31 total procedures and were treated with aspirin/prasugrel. Those patients who received aspirin/prasugrel DAPT were identified pre-procedurally to be clopidogrel non-responders. Both treatment groups had a similar percentage of patients undergoing aneurysm coiling, stent assisted aneurysm coiling, aneurysm Onyx embolization, aneurysm pipeline embolization device treatment, extra/intracranial carotid artery angioplasty and stenting, and dural arteriovenous fistula coil embolization. A total of eight (9.3%) hemorrhagic complications were observed, two (3.6%) in the aspirin/clopidogrel group and six (19.4%) in the aspirin/prasugrel group (p=0.02). No differences were noted in hemorrhage rates for each procedure between treatment groups, nor were there any differences in thrombotic complications between groups.

Conclusion: Our results suggest that DAPT with aspirin/prasugrel may predispose to a higher risk of hemorrhage during neurointerventional surgery compared with DAPT with aspirin/clopidogrel.

Figure 1

(A) Anteroposterior view of the cerebral vasculature following a left vertebral artery contrast injection. A large aneurysm at the basilar apex is visualized. (B) Active extravasation of contrast agent from the lateral wall of the basilar artery (denoted by arrowhead). (C) Repeat cerebral catheter angiogram with injection of the left vertebral artery showing near complete aneurysm occlusion after endovascular coil embolization. (D–F) Serial sections from a non-contrast head CT showing diffuse hyperdensity within the basilar cisterns, bilateral Sylvian fissures and intraventricular space with obstructive hydrocephalus.

Figure 2

(A) Anteroposterior view of the cerebral circulation following a right common carotid artery injection demonstrating a large cavernous carotid aneurysm. (B) Active extravasation from the proximal right cervical carotid artery (denoted by arrowhead). (C) Anteroposterior skull radiographs showing the pipeline embolization device deployed within the cavernous carotid artery. (D) Non-contrast neck CT demonstrating soft tissue stranding and likely hematoma in the area adjacent to the carotid injury (asterisks denote cervical carotid artery and internal jugular vein). (E) Non-contrast pelvic CT showing a large hematoma centered within the right abdominal wall.

Figure 3

(A) Anteroposterior view of the cerebral circulation following a left common carotid artery injection showing a large aneurysm arising from the cavernous carotid artery. (B) Repeat cerebral catheter angiography immediately following deployment of several pipeline embolization devices (PEDs) showing reduction of contrast within the aneurysm. (C) Lateral skull radiographs showing the PED deployed within the cavernous carotid artery. (D) Non-contrast head CT showing a small right frontal intraparenchymal hemorrhage.

Figure 4

(A) Anteroposterior view of the cerebral circulation following a right vertebral artery contrast injection showing a large left superior cerebellar artery aneurysm. (B) Repeat cerebral catheter angiogram following near complete endovascular coil embolization. (C) Non-contrast head CT demonstrating a small focus of intraparenchymal hemorrhage within the right cerebellar hemisphere.