Whole blood aggregometry prior to Pipeline embolization device treatment of intracranial aneurysms: defining an optimal platelet inhibition cutoff value for clopidogrel

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OBJECTIVE

Dual antiplatelet therapy is required for the treatment of intracranial aneurysms with the Pipeline embolization device (PED). Platelet function testing (PFT) is often used to assess the efficacy of the antiplatelet regimen prior to PED placement. The optimal impedance values for whole blood aggregometry in this setting have not been defined.

METHODS

A retrospective review of a prospectively maintained database was performed for the years 2011–2015 to identify patients with intracranial aneurysms treated with the PED who underwent pretreatment PFT using whole blood aggregometry. Antiplatelet therapy was not altered based on PFT results; all patients remained on standard doses of aspirin and clopidogrel. Clinical, radiographic, and laboratory data were analyzed to identify the optimal cutoff impedance value for clopidogrel responsiveness using the receiver operating characteristic curve and Youden’s index.

RESULTS

Forty-nine patients underwent 53 endovascular procedures for the treatment of 76 aneurysms using the PED. The majority of these aneurysms were located in the anterior circulation (90.8%) and affected the internal carotid artery (89.5%). Patients in 30 procedures (56.6%) were identified as clopidogrel responders based on the manufacturer cutoff value (< 6 Ω). Thromboembolic complications occurred in 13 (24.5%) procedures; patients in 6 (11.3%) cases were symptomatic and those in 3 (5.7%) cases had ischemic strokes. Eleven of the 13 (84.6%) thromboembolic complications occurred in clopidogrel nonresponders. An impedance value of ≥ 6 Ω was independently associated with thromboembolic complications. The optimal electrical impedance value was identified as ≥ 6 Ω (sensitivity 84.6%, specificity 70.0%, area under the curve 0.77) for identifying clopidogrel nonresponders.

CONCLUSIONS

Thromboembolic complications are more common following PED placement in patients who do not respond adequately to clopidogrel. Clopidogrel nonresponders can be identified using pretreatment whole blood aggregometry. The optimal cutoff value to categorize a patient as a clopidogrel nonresponder when using whole blood aggregometry is ≥ 6 Ω.

ABBREVIATIONS DAPT = dual antiplatelet therapy; DSA = digital subtraction angiography; ICA = internal carotid artery; LTA = light transmission aggregometry; mRS = modified Rankin Scale; PED = Pipeline embolization device; PFT = platelet function testing; PRU = P2Y12 reaction unit; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage; WBA = whole blood aggregometry.
Article Information

Contributor Notes

Correspondence Paul M. Foreman: University of Alabama at Birmingham, AL. pforeman@uabmc.edu.INCLUDE WHEN CITING Published online November 16, 2018; DOI: 10.3171/2018.6.JNS181044.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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