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Utility of P2Y12 Reactive Unit Assessment on Ticagrelor in Cerebral Aneurysms Treated with Intracranial Stenting and
Christian O Bohan1, Mirja M Wirtz1, Philipp Hendrix2
1Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.
Insights
Platelet function testing in patients receiving ticagrelor for neurovascular procedures is crucial. A P2Y12 reactive unit (PRU) range of 0-100 may indicate a safer profile, reducing thromboembolic risks.
Area of Science:
- Neuroendovascular surgery
- Pharmacology
- Cardiology
Background:
- Dual antiplatelet therapy (aspirin and clopidogrel) is standard for neurointerventional stenting and flow diversion.
- Platelet function testing identifies clopidogrel hypo- or hyper-responders.
- Ticagrelor is an alternative antiplatelet agent, necessitating evaluation of its associated platelet function testing parameters.
Observation:
- Retrospective review of 28 patients undergoing cerebral aneurysm treatment with ticagrelor (May 2017-August 2019).
- Treatments included flow diversion (55.2%) and stent-assisted coiling (44.8%).
- Platelet function testing measured P2Y12 reactive units (PRUs) and correlated with procedural complications.
Findings:
- Four thromboembolic complications (13.8%) occurred; no hemorrhagic complications were observed.
- Patients with PRU >100 had a 50% rate of thromboembolic complications.
- Patients with PRU ≤100 experienced no complications.
Implications:
- Thromboembolic risk is associated with ticagrelor therapy, correlating with PRUs.
- A potentially safer PRU range for ticagrelor is 0-100, lower than for clopidogrel (60-210).
- Further studies are needed to validate the optimal PRU range for ticagrelor.
Background:
Dual antiplatelet therapy consisting of aspirin and clopidogrel is the standard of care for neurointerventional stenting and flow diversion. Platelet function testing has been increasingly performed to identify patients with a hypo- or hyper-response to clopidogrel. Ticagrelor has been a popular alternative antiplatelet agent for such patients. We assessed the role of platelet function testing in patients receiving ticagrelor and undergoing stenting or flow diversion.
Methods:
The data from patients who had undergone stent-assisted coiling or Pipeline flow diversion of a cerebral aneurysm with ticagrelor therapy at any point during their treatment course from May 2017 to August 2019 at a single academic institution in the United States were retrospectively reviewed. Platelet function testing was used to determine the P2Y12 reactive units (PRUs), and the results were correlated with the procedural complications.
Results:
A total of 28 patients with 29 aneurysms were treated while receiving ticagrelor. Of the 29 aneurysms, 16 (55.2%) were treated with flow diversion and 13 (44.8%) with stent-assisted coiling. Four thromboembolic complications (13.8%) and no hemorrhagic complications developed. Of the 8 patients with ≥1 PRU value >100, 4 (50%) had experienced a thromboembolic complication. The patients without a PRU value >100 did not experience any complications.
Conclusion:
A risk of thromboembolic complications exists for patients receiving ticagrelor, which correlated with the PRUs in the present preliminary study. The findings from the present study suggest that the safe PRU range for patients receiving ticagrelor should be shifted to 0-100, which is lower than that of clopidogrel, thought to be 60-210. Further validation of the optimal PRU range for patients receiving ticagrelor is necessary.
