P2Y12 Inhibitor Administration for Intracranial Stenting Procedures, the Usefulness of Efficiency Monitoring

Abstract

Objective: The implantation of stents in the cerebral arteries for aneurism exclusions requires the administration of dual antiplatelet therapy. This medication increases the haemorrhage risk, while some patients develop a phenomenon called "high on-treatment platelet reactivity," exposing to the material thrombosis. The focus on the platelet function monitoring in this context is key to the success of this procedure, allowing for identification of the different population of patients for the adjustment of the prescription for which antiplatelet therapy to use, to get the best balance between the prevention of material thrombosis and haemorrhage risk. This study focuses on the use of platelet function monitoring with Multiplate (Roche, Boulogne-Billancourt, France), in the context of a prescription of clopidogrel and its possible replacement by ticagrelor for resistant patients.

Methods: The study is an observational retrospective cohort monocentric study. Patients were sampled for a Multiplate analysis with no antiplatelets treatment, then the day before the procedure, a new Multiplate analysis is proceeded with after 5 days of clopidogrel and aspirin. If adenosine diphosphate (ADP) test was above 300 area under the curve on Multiplate, it was decided to introduce ticagrelor. The primary endpoint was the occurrence of thromboembolic or haemorrhagic events during the first 30 days postoperatively.

Results: 104 patients treated electively with a stent for an intracranial aneurysm were included from January 2016 to June 2020; 77 patients were classified as responder to clopidogrel and 27 had to be switched from clopidogrel to ticagrelor; 9 patients under clopidogrel (8.6%) had an ischaemic event and 1 under ticagrelor (1%). No patient had a haemorrhagic event under clopidogrel and 3 under ticagrelor (2.8%). Comparing clopidogrel and ticagrelor group regarding ischemic or haemorrhagic event endpoints, the difference was not statistically significant: (p = 0.37), but statistically significant regarding fatal event (p = 0.02) in disfavour of ticagrelor.

Conclusion: The use of platelet function monitoring makes it possible to determine the therapeutic effectiveness of P2Y12 inhibitors, and thus to provide the most appropriate antiplatelets treatment for the patient when an intracranial stent is placed.

Keywords: Multiplate; P2Y12 inhibitor; clopidogrel; dual antiplatelet therapy; ticagrelor.

Fig. 1. Flowchart of patientsʼ repartition

Fig. 2. ADP test evolution regarding drug administration and events. ADP, adenosine diphosphate