From the Research
The ideal P2Y12 reaction unit (PRU) level for endovascular flow-diverting stent placement in cerebral aneurysms is between 0-100 PRU, with an optimal target of approximately 50-80 PRU, as suggested by the most recent study 1.
Key Considerations
- The study published in 2025 1 provides the most recent and highest quality evidence, indicating that the majority of periprocedural ticagrelor PRUs were <100, and PRUs at the time point of thromboembolic complications were >120.
- The findings from this study suggest that safe ticagrelor PRU levels might be lower than those commonly applied for clopidogrel.
- Patients should begin dual antiplatelet therapy (DAPT) with aspirin and ticagrelor, and P2Y12 testing should be performed to ensure the optimal PRU range is achieved.
- For patients with excessive platelet inhibition (PRU <50), reduce the ticagrelor dose or switch to a different agent, and for those with inadequate platelet inhibition (PRU >100), consider alternative antiplatelet agents.
Management Strategy
- Start DAPT with aspirin 325mg daily and ticagrelor 90mg twice daily at least 7 days before the procedure.
- Perform P2Y12 testing 4-6 hours after the loading dose or after 5-7 days of maintenance therapy.
- Continue DAPT for 3-6 months after stent placement, then transition to aspirin monotherapy indefinitely.
- Monitor patients closely for signs of thromboembolic or hemorrhagic complications, and adjust the antiplatelet therapy as needed.
Rationale
The optimal PRU range of 0-100, as suggested by the most recent study 1, balances the risk of thromboembolic complications from inadequate platelet inhibition against the risk of hemorrhagic complications from excessive inhibition, which is particularly critical in neurointerventional procedures where bleeding can have catastrophic consequences.