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The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device.

Publication ,  Journal Article
Atallah, E; Saad, H; Bekelis, K; Chalouhi, N; Tjoumakaris, S; Hasan, D; Eller, J; Stidd, D; Rosenwasser, RH; Jabbour, P
Published in: J Neurosurg
November 1, 2018

OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016. Patients allergic, or having less than 30% platelet inhibition, to a daily 75-mg dose of clopidogrel received 10 mg of prasugrel daily (n = 20) or 90 mg of ticagrelor twice daily (n = 2). The mean (± SD) follow-up duration was 15.8 ± 12.4 months. The primary outcome was the modified Rankin Scale (mRS) score registered before discharge and at each follow-up visit. To control confounding, multivariable mixed-effects logistic regression and propensity score conditioning were used.RESULTSTwenty-six (5.9%) of 437 patients presented with a subarachnoid hemorrhage (SAH). The mean patient age was 56.3 years, and 62 were women (14.2%). One of the 7 patients lost to follow-up received prasugrel. One patient was allergic to clopidogrel and prasugrel simultaneously. All patients receiving prasugrel or ticagrelor (n = 22) had an mRS score ≤ 2 on their latest follow-up visit (mean score 0.67 ± 1.15). In a multivariate analysis, clopidogrel did not affect the mRS score on last follow-up (p = 0.14). Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (OR 0.17, 95% CI 0.01-2.70, p = 0.21), an increased thromboembolic complication rate (OR 0.46, 95% CI 0.12-1.67, p = 0.24), or an increased hemorrhagic event rate (OR 0.39, 95% CI 0.91-1.64, p = 0.20). None of the patients receiving prasugrel or ticagrelor died or suffered a long-term recurrence or a hemorrhagic event; only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. Three patients taking clopidogrel died during the study: 2 from acute SAH and 1 from intraparenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR 2.18, 95% CI 0.11-43.27, p = 0.61). The same associations were present in propensity score-adjusted models.CONCLUSIONSIn a cohort of patients treated with PEDs, prasugrel (10 mg/day) was a safe alternative to clopidogrel-resistant or clopidogrel-allergic patients, or nonresponders.

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Published In

J Neurosurg

DOI

EISSN

1933-0693

Publication Date

November 1, 2018

Volume

129

Issue

5

Start / End Page

1130 / 1135

Location

United States

Related Subject Headings

  • Treatment Outcome
  • Subarachnoid Hemorrhage
  • Retrospective Studies
  • Prasugrel Hydrochloride
  • Platelet Aggregation Inhibitors
  • Neurology & Neurosurgery
  • Middle Aged
  • Male
  • Intracranial Aneurysm
  • Humans
 

Citation

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Atallah, E., Saad, H., Bekelis, K., Chalouhi, N., Tjoumakaris, S., Hasan, D., … Jabbour, P. (2018). The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device. J Neurosurg, 129(5), 1130–1135. https://doi.org/10.3171/2017.5.JNS162663
Atallah, Elias, Hassan Saad, Kimon Bekelis, Nohra Chalouhi, Stavropoula Tjoumakaris, David Hasan, Jorge Eller, David Stidd, Robert H. Rosenwasser, and Pascal Jabbour. “The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device.J Neurosurg 129, no. 5 (November 1, 2018): 1130–35. https://doi.org/10.3171/2017.5.JNS162663.
Atallah E, Saad H, Bekelis K, Chalouhi N, Tjoumakaris S, Hasan D, et al. The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device. J Neurosurg. 2018 Nov 1;129(5):1130–5.
Atallah, Elias, et al. “The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device.J Neurosurg, vol. 129, no. 5, Nov. 2018, pp. 1130–35. Pubmed, doi:10.3171/2017.5.JNS162663.
Atallah E, Saad H, Bekelis K, Chalouhi N, Tjoumakaris S, Hasan D, Eller J, Stidd D, Rosenwasser RH, Jabbour P. The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device. J Neurosurg. 2018 Nov 1;129(5):1130–1135.

Published In

J Neurosurg

DOI

EISSN

1933-0693

Publication Date

November 1, 2018

Volume

129

Issue

5

Start / End Page

1130 / 1135

Location

United States

Related Subject Headings

  • Treatment Outcome
  • Subarachnoid Hemorrhage
  • Retrospective Studies
  • Prasugrel Hydrochloride
  • Platelet Aggregation Inhibitors
  • Neurology & Neurosurgery
  • Middle Aged
  • Male
  • Intracranial Aneurysm
  • Humans