From the Guidelines
The ideal P2Y12 reaction unit (PRU) level for endovascular flow-diverting stent placement in cerebral aneurysms should be between 60-150 PRU, with a target range of 60-100 PRU for optimal platelet inhibition. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of balancing platelet inhibition with the risk of hemorrhage 1.
Key Considerations
- Patients typically require dual antiplatelet therapy (DAPT) with aspirin 325mg daily and a P2Y12 inhibitor such as clopidogrel 75mg daily, started 5-7 days before the procedure.
- P2Y12 testing should be performed 4-24 hours before the intervention to ensure adequate platelet inhibition.
- If a patient shows clopidogrel resistance (PRU >150), alternative P2Y12 inhibitors like ticagrelor (90mg twice daily) or prasugrel (10mg daily) may be used.
- Post-procedure, DAPT is typically continued for 3-6 months, followed by aspirin monotherapy indefinitely.
Rationale
Adequate platelet inhibition is crucial because flow diverting stents have a high metal surface area that can trigger platelet aggregation and thrombus formation, potentially leading to thromboembolic complications or in-stent thrombosis. However, excessive inhibition (PRU <60) increases hemorrhagic risk, requiring a careful balance for each patient. The most recent guidelines recommend a P2Y12 receptor inhibitor in addition to aspirin, and maintained over 12 months unless there are contraindications or an excessive risk of bleeding 1.
Alternative Options
- Prasugrel (60 mg loading dose, 10 mg daily) or ticagrelor (180 mg loading dose, 90 mg twice daily) may be considered as alternative P2Y12 inhibitors.
- Clopidogrel (300-600 mg loading dose, 75 mg daily) may be used when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated.
From the Research
Ideal P2Y12 Level for Endovascular Flow-Diverting Stent Placement
- The ideal P2Y12 level for endovascular flow-diverting stent placement in cerebral aneurysms is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- However, the use of P2Y12 antagonists such as clopidogrel and ticagrelor is mentioned in the context of dual antiplatelet therapy for patients undergoing flow-diverting stent placement or stent-assisted coiling for cerebral aneurysms 3, 5, 6.
- A study comparing ticagrelor and clopidogrel in patients with unruptured cerebral aneurysms undergoing stent-assisted coiling or flow-diversion treatment found that ticagrelor appears to be as effective and safe as clopidogrel 3.
- Another study evaluating the safety and efficacy of flow diverter stents in the treatment of intracranial aneurysms less than 5 mm mentioned the use of neurointerventional stent medication (double antiplatelet) but did not specify the ideal P2Y12 level 5.
- The management of complications associated with flow-diverting stent placement, including the use of antiplatelet therapy, is discussed in several studies 2, 4, 6, but the ideal P2Y12 level is not explicitly stated.
Antiplatelet Therapy and P2Y12 Levels
- The use of antiplatelet therapy, including P2Y12 antagonists, is crucial in patients undergoing flow-diverting stent placement or stent-assisted coiling for cerebral aneurysms 3, 5, 6.
- However, the optimal level of P2Y12 inhibition is not well established, and further studies are needed to determine the ideal P2Y12 level for these patients 3.
- The studies provided do not offer a clear answer to the question of the ideal P2Y12 level for endovascular flow-diverting stent placement in cerebral aneurysms, highlighting the need for further research in this area 2, 3, 4, 5, 6.