Antiplatelet complications
It is known that stent-assisted coiling (SAC) for ruptured wide-neck intracranial aneurysms has a good efficacy; however, there is an increased risk of perioperative hemorrhagic complications due to the need for dual antiplatelet therapy (DAPT). 1)
Especially, invasive procedures like external ventricular drainage (EVD) or ventriculoperitoneal shunt (VPS), which are inevitable for patients presenting with hydrocephalus, might lead to intracerebral hemorrhages (ICH) or contusions along the trajectory of the catheters. However, abrupt cessation of antiplatelets should be avoided, since it might increase the risk of thromboembolism, especially during the acute period after stent placement 2).
Balancing the risk of stent-associated thromboembolism and perioperative hemorrhagic events is challenging. There are no evidence-based guidelines for the management of DAPT in patients who have recently undergone placement of neurovascular stent and require intracranial surgical procedures. Previous retrospective studies suggested that VPS in patients on DAPT might be associated with an increased risk of ICH; however most of the hemorrhages were asymptomatic
The effect of the loading dose of antiplatelets prior to the stent coiling procedure in an unsecured wide necked ruptured intracranial aneurysm is not known.
In the series of Lodi et al carefully selected patients, therapeutic dual antiplatelet loading prior to Stent-assisted coiling of ruptured wide necked intracranial aneurysm was not associated with increased bleeding complications. However, thromboembolic events remain the main challenge. Further study is required to confirm the safety of antiplatelet loading in stent assisted ruptured intracranial aneurysm coiling 3).