Management of antiplatelet therapy in patients undergoing neuroendovascular procedures

Keri S. Kim Department of Pharmacy Practice, University of Illinois Medical Center at Chicago, Illinois;

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Justin F. Fraser Departments of Neurological Surgery, Neurology, Radiology, and Anatomy and Neurobiology, Center for Advanced Translational Stroke Science;

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Stephen Grupke Department of Neurological Surgery, UK HealthCare;

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Aaron M. Cook UK HealthCare; and
University of Kentucky College of Pharmacy, Lexington, Kentucky

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Neuroendovascular techniques for treating cerebral aneurysms and other cerebrovascular pathology are increasingly becoming the standard of care. Intraluminal stents, aneurysm coils, and other flow diversion devices typically require concomitant antiplatelet therapy to reduce thromboembolic complications. The variability inherent with the pharmacodynamic response to common antiplatelet agents such as aspirin and clopidogrel complicates optimal selection of antiplatelet agents by clinicians. This review serves to discuss the literature related to antiplatelet use in neuroendovascular procedures and provides recommendations for clinicians on how to approach patients with variable response to antiplatelet agents, particularly clopidogrel.

ABBREVIATIONS

ACS = acute coronary syndrome; ARU = aspirin reaction unit; CYP = cytochrome P450; DAT = dual antiplatelet therapy; DWI = diffusion-weighted imaging; GRAVITAS = Gauging Responsiveness with a VerifyNow P2Y12 assay: Impact on Thrombosis and Safety; HTPR = high on-treatment platelet reactivity; LTA = light/optical transmission aggregometry; LTPR = low on-treatment platelet reactivity; PCI = percutaneous coronary intervention; PED = Pipeline embolization device; PRU = P2Y12 reaction unit.
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