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Review
. 2023 Aug 9;11(8):2234.
doi: 10.3390/biomedicines11082234.

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms

Benjamen M Meyer  1 , Jessica K Campos  2 , Jonathan C Collard de Beaufort  3 , Ivette Chen  4 , Muhammad Waqas Khan  5 , Gizal Amin  5 , David A Zarrin  6 , Brian V Lien  2 , Alexander L Coon  5
Affiliations
Review

Trends in Dual Antiplatelet Therapy Use for Neurointerventional Procedures for the Management of Intracranial Aneurysms

Benjamen M Meyer et al. Biomedicines. .

Abstract

The use of periprocedural dual antiplatelet therapy (DAPT) has significantly evolved along with innovations in the endovascular management of intracranial aneurysms. Historically, aspirin and clopidogrel have been the most commonly employed regimen due to its safety and efficacy. However, recent studies highlight the importance of tailoring DAPT regimens to individual patient characteristics which may affect clopidogrel metabolism, such as genetic polymorphisms. In the present report, a systematic review of the literature was performed to determine optimal antiplatelet use with flow diverting stents, intracranial stents, intrasaccular devices, and stent-assisted coiling. Studies were analyzed for the number of aneurysms treated, DAPT regimen, and any thromboembolic complications. Based on inclusion criteria, 368 studies were selected, which revealed the increasing popularity of alternative DAPT regimens with the aforementioned devices. Thromboembolic or hemorrhagic complications associated with antiplatelet medications were similar across all medications. DAPT with ticagrelor, tirofiban, or prasugrel are effective and safe alternatives to clopidogrel and do not require enzymatic activation. Further clinical trials are needed to evaluate different antiplatelet regimens with various devices to establish highest-level evidence-based guidelines and recommendations.

Keywords: dual antiplatelet therapy; flow diverting stents; intracranial aneurysm; intracranial stenting; monotherapy; stent-assisted coiling.

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Conflict of interest statement

Alexander L. Coon is a consultant for Medtronic Neurovascular, MicroVention-Terumo, Stryker Neurovascular, Rapid Medical; and a consultant for Avail MedSystems, Imperative Care, InNeuroCo, Medtronic Neurovascular, MicroVention-Terumo, Q’apel, Rapid Medical, Stryker Neurovascular, and Sequent Medical; a proctor for MicroVention-Termo, Stryker Neurovascular, and Medtronic Neurovascular. All other authors have no conflict of interest. No author received financial support in conjunction with the generation of this submission.

Figures

Figure 1
Figure 1
PRISMA Flow Diagram.
Figure 2
Figure 2
Test for difference of complication rates by drug type for three procedures. CL is the confidence level at which one can reject the null hypothesis of equality of a complication rate versus that of baseline. A higher CL is indicative that one of the drugs is more effective. Despite CL being high for tirofiban, there is a large margin of error due to a low number of complications.
Figure 3
Figure 3
Difference of complication rates test between DAPT drugs for three procedures with associated confidence level.
Figure 4
Figure 4
Difference of hemorrhagic complication rates between DAPT drugs for three procedures with associated confidence levels.
Figure 5
Figure 5
Test for difference of complication rates by drug type for three procedures. CL is the confidence level at which one can reject the null hypothesis of equality of a complication rate versus that of baseline.
Figure 6
Figure 6
Difference of ischemic and thrombotic complication rates between DAPT drugs for three procedures with associated confidence levels.
See this image and copyright information in PMC

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