Dual antiplatelet therapy [Neurosurgery Wiki]

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====== Dual antiplatelet therapy ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1h7Su3P88Y-o0KJJTFSXFU1-Yr3GXshW-qrsazIpPLSQzllkx6/?limit=15&utm_campaign=pubmed-2&fc=20250227064103}}

===== Indications =====

Adequate dual [[antiplatelet therapy]] is imperative when performing neurovascular [[stenting]] procedures. 

After stenting, the patient remains on dual antiplatelet therapy ([[ASA]] + [[Plavix]]) for at least a month and ASA alone indefinitely.

Currently, no consensus for the ideal AP regimen exists. 

The most frequent included [[acetylsalicylic acid]] (ASA) 325 mg+[[Plavix]] 75 mg daily (for 7 days prior) and ASA 325 mg+Plavix 75 mg daily (for 5 days prior) for routine placement of intracranial and cervical stents, respectively. For emergency placement, ASA 325 mg+Plavix 600 mg (at time of surgery) was the most frequently used.

Significant heterogeneity in dual antiplatelet regimens following [[Pipeline Embolization Device]] (PED) placement and associated costs, exists at major academic [[neurovascular center]]s. The most commonly used first line dual antiplatelet regimen consists of [[aspirin]] and [[clopidogrel]]. Two major alternate protocols involving [[ticagrelor]] and [[prasugrel]], are administered to clopidogrel hypo-responders. The optimal dual antiplatelet regimen for patients with cerebrovascular conditions has not been established, given limited prospective data within the neurointerventional literature
((Gupta R, Moore JM, Griessenauer CJ, Adeeb N, Patel AS, Youn R, Poliskey K,
Thomas AJ, Ogilvy CS. Assessment of Dual Antiplatelet Regimen for Pipeline
Embolization Device Placement: A Survey of Major Academic Neurovascular Centers
in the United States. World Neurosurg. 2016 Sep 15. pii: S1878-8750(16)30839-7.
doi: 10.1016/j.wneu.2016.09.013. [Epub ahead of print] PubMed PMID: 27641263.
)).

Given its importance, evidence based protocols are imperative. Minimal literature exists focusing on neurovasculature, and therefore understanding current practice patterns represents a first step toward generating these protocols.
((Faught RW, Satti SR, Hurst RW, Pukenas BA, Smith MJ. Heterogeneous practice
patterns regarding antiplatelet medications for neuroendovascular stenting in the
USA: a multicenter survey. J Neurointerv Surg. 2014 Jan 3. doi:
10.1136/neurintsurg-2013-010954. [Epub ahead of print] PubMed PMID: 24391160.)).
----
[[Dual antiplatelet therapy]] (e.g. [[ASA]] + [[Plavix]]®) are mandatory for 4 weeks (90 days is preferable
((Nuttall GA, Brown MJ, Stombaugh JW, et al. Time and cardiac risk of surgery after bare-metal stent percutaneous coronary intervention. Anesthesiology. 2008; 109:588–595))
after placement of a bare metal cardiac stent, and for at least 1 year with drug-eluting stents (DES) (the risk declines from ≈ 6% to ≈ 3%)
((Rabbitts JA, Nuttall GA, Brown MJ, et al. Cardiac risk of noncardiac surgery after percutaneous coronary intervention with drug-eluting stents. Anesthesiology. 2008; 109:596–604)).
Even short gaps in drug therapy (e.g. to perform neurosurgical procedures) is associated with significant risk of acute stent occlusion (and therefore elective surgery during this time is discouraged
((Landesberg G, Beattie WS, Mosseri M, et al. Perioperative myocardial infarction. Circulation. 2009; 119:2936–2944))
DES is so effective in suppressing endothelialization that lifetime dual antiplatelet therapy may be required. Bridging DES patients with antithrombin, anticoagulants, or glycoprotein IIb/IIIa agents has not been proven effective
((Landesberg G, Beattie WS, Mosseri M, et al. Perioperative myocardial infarction. Circulation. 2009; 119:2936–2944)).


===== Complications =====

[[Dual antiplatelet therapy complications]]


===== Case reports =====

Ravina et al., presented in [[2018]] a [[literature review]] and an illustrative case of an 18-year-old man who presented with progressive [[headache]]s and was found to have a large, unruptured [[basilar apex aneurysm]] involving the origins of bilateral [[superior cerebellar artery]] and [[posterior cerebral artery]]. Given the small [[posterior communicating artery]] and complexity of the aneurysm, proximal [[basilar artery]] occlusion with unilateral [[superficial temporal artery]]-to-superior cerebellar artery bypass was recommended. Despite [[antiplatelet]] treatment with [[acetylsalicylic acid]] pre- and postoperatively, the patient developed acute [[ischemia]] of the [[brainstem]] and [[cerebellum]] as well as an embolic left [[temporal lobe]] [[infarct]]. The patient received [[dual antiplatelet therapy]] starting postoperative day 6 following which he experienced no new infarcts and made a significant neurologic recovery. The current evidence suggests that proximal BA occlusion in complex BA apex aneurysm cases is thrombogenic and can be especially dangerous if [[thrombosis]] occurs suddenly in aneurysms without pre-existing intraluminal thrombus. Dual antiplatelet therapy during the first postoperative week presents a possible strategy for reducing the risk of ischemia due to sudden aneurysm thrombosis
((Ravina K, Strickland BA, Buchanan IA, Rennert RC, Kim PE, Fredrickson VL,
Russin JJ. Postoperative antiplatelet therapy in the treatment of complex basilar
apex aneurysms implementing Hunterian ligation and extracranial-to-intracranial
bypass: review of the literature with an illustrative case report. World
Neurosurg. 2018 Dec 8. pii: S1878-8750(18)32798-0. doi:
10.1016/j.wneu.2018.11.237. [Epub ahead of print] Review. PubMed PMID: 30537547.
)).

===== References =====