Incidence of cerebral ischemic events after discontinuation of clopidogrel in patients with intracranial aneurysms treated with stent-assisted techniques

Clinical article

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Object

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.

Methods

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.

Results

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.

Conclusions

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.

Abbreviations used in this paper:DAT = dual antiplatelet therapy; SAH = subarachnoid hemorrhage; TIA = transient ischemic attack.

Article Information

* Drs. Rossen and Chalouhi contributed equally to this work.

Address correspondence to: David M. Hasan, M.D., Department of Neurosurgery, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, Iowa 52242. email: david-hasan@uiowa.edu.

Please include this information when citing this paper: published online September 7, 2012; DOI: 10.3171/2012.8.JNS12185.

© AANS, except where prohibited by US copyright law.

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References

  • 1

    Brott TBogousslavsky J: Treatment of acute ischemic stroke. N Engl J Med 343:7107222000

  • 2

    Lee DHArat AMorsi HShaltoni HHarris JRMawad ME: Dual antiplatelet therapy monitoring for neurointerventional procedures using a point-of-care platelet function test: a single-center experience. AJNR Am J Neuroradiol 29:138913942008

  • 3

    Leon MBBaim DSPopma JJGordon PCCutlip DEHo KK: A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. N Engl J Med 339:166516711998

  • 4

    Mocco JFargen KMAlbuquerque FCBendok BRBoulos ASCarpenter JS: Delayed thrombosis or stenosis following enterprise-assisted stent-coiling: is it safe? Midterm results of the interstate collaboration of enterprise stent coiling. Neurosurgery 69:9089142011

  • 5

    Moret JCognard CWeill ACastaings LRey A: [Reconstruction technic in the treatment of wide-neck intracranial aneurysms. Long-term angiographic and clinical results. Apropos of 56 cases.]. J Neuroradiol 24:30441997. (Fr)

  • 6

    Moussa IOetgen MRoubin GColombo AWang XIyer S: Effectiveness of clopidogrel and aspirin versus ticlopidine and aspirin in preventing stent thrombosis after coronary stent implantation. Circulation 99:236423661999

  • 7

    Moussa IDColombo A: Antiplatelet therapy discontinuation following drug-eluting stent placement: dangers, reasons, and management recommendations. Catheter Cardiovasc Interv 74:104710542009

  • 8

    Piotin MBlanc RSpelle LMounayer CPiantino RSchmidt PJ: Stent-assisted coiling of intracranial aneurysms: clinical and angiographic results in 216 consecutive aneurysms. Stroke 41:1101152010

  • 9

    Riedel CHTietke MAlfke KStingele RJansen O: Subacute stent thrombosis in intracranial stenting. Stroke 40:131013142009

  • 10

    Sambu NWarner TCurzen N: Clopidogrel withdrawal: is there a “rebound” phenomenon?. Thromb Haemost 105:2112202011

  • 11

    Schömig ANeumann FJKastrati ASchühlen HBlasini RHadamitzky M: A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronaryartery stents. N Engl J Med 334:108410891996

  • 12

    von Beckerath NPogatsa-Murray GWieczorek ASibbing DSchömig AKastrati A: Correlation of a new point-of-care test with conventional optical aggregometry for the assessment of clopidogrel responsiveness. Thromb Haemost 95:9109112006

  • 13

    Wiviott SDBraunwald EMcCabe CHMontalescot GRuzyllo WGottlieb S: Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357:200120152007

  • 14

    Yamada NKCross DT IIIPilgram TKMoran CJDerdeyn CPDacey RG Jr: Effect of antiplatelet therapy on thromboembolic complications of elective coil embolization of cerebral aneurysms. AJNR Am J Neuroradiol 28:177817822007

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