The Use of Prasugrel and Ticagrelor in Pipeline Flow Diversion

Authors

Elias Atallah, MD, Thomas Jefferson UniversityFollow
Hassan Saad, MD, Thomas Jefferson UniversityFollow
Kimon Bekelis, MD, Thomas Jefferson UniversityFollow
Nohra Chalouhi, MD, Thomas Jefferson UniversityFollow
Stavropoula Tjoumakaris, MD, Thomas Jefferson UniversityFollow
David Hasan, MD, Thomas Jefferson UniversityFollow
Gorge Eller, MD, Thomas Jefferson University
David Stidd, MD, Thomas Jefferson UniversityFollow
Robert H. Rosenwasser, MD, MBA, FACS, FAHA MD, Thomas Jefferson UniversityFollow
Pascal Jabbour MD, Thomas Jefferson UniversityFollow

Abstract

Background:

Despite the routine clopidogrel/aspirin anti-platelet therapy, complications like thromboembolism, continue to be encountered with PED. We studied the safety and the efficacy of prasugrel in the management of clopidogrel non-responders treated for intracranial aneurysms.

Methods:

437 consecutive neurosurgery patients were identified between January 2011 and May 2016. Patients allergic or having <30% platelet-inhibition with a daily 75mg of clopidogrel were dispensed 10mg of prasugrel daily (n=20) or 90mg of ticagrelor twice daily (n=2). The average follow-up was 15.8 months (SD=12.4 months). Patient clinical well being was evaluated with the modified Rankin Scale (mRS) registered before the discharge and at each follow-up visit. To control confounding we used multivariable mixed-effects logistic regression and propensity score conditioning.

Results:

26 of 437(5.9%) patients (mean of age 56.3 years; 62 women [14,2%]) presented with a sub-arachnoid hemorrhage. 1 patient was allergic to clopidogrel and prasugrel simultaneously. All the patients receiving prasugrel (n=22) had a mRS<2 on their latest follow-up visit (mean=0.67; SD=1.15). In a multivariate analysis, clopidogrel did not affect the mRS on last follow-up, p=0.14. Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (odds ratio[OR], 0.17; 95%Confidence Interval [CI95%], 0.01-2.70; p=0.21) neither with an increased thromboembolic accident rate (OR, 0.46; CI95%, 0.12-1.67; p=0.36) nor with an increased hemorrhagic event rate (OR, 0.39; CI95%,0.91-1.64; p=0.20). None of the patients receiving prasugrel deceased or had a long-term recurrence nor a hemorrhagic event, only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. 3 patients on clopidogrel passed during the study: (2) from acute SAH and (1) from intra-parenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR, 2.18; CI95%,0.11-43.27; p=0.61). The same associations were present in propensity score adjusted models.

Conclusion:

In a cohort of patients treated with PED for their intracranial aneurysms, prasugrel (10mg/day) is a safe alternative to clopidogrel resistant, allergic or non-responders.

Recommended Citation

Atallah, MD, Elias; Saad, MD, Hassan; Bekelis, MD, Kimon; Chalouhi, MD, Nohra; Tjoumakaris, MD, Stavropoula; Hasan, MD, David; Eller, MD, Gorge; Stidd, MD, David; Rosenwasser, MD, MBA, FACS, FAHA MD, Robert H.; and Jabbour, Pascal MD (2018) "The Use of Prasugrel and Ticagrelor in Pipeline Flow Diversion," JHN Journal: Vol. 13: Iss. 2, Article 5.
DOI: https://doi.org/10.29046/JHNJ.013.2.005
Available at: https://jdc.jefferson.edu/jhnj/vol13/iss2/5