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Antiplatelet Management for Stent-Assisted Coiling and Flow Diversion of Ruptured Intracranial Aneurysms: A DELPHI
J M Ospel1,2, P Brouwer3,4, F Dorn5
1Department of Clinical Neurosciences (J.M.O., M.G.), University of Calgary, Calgary, Alberta, Canada.
Insights
Limited data exists on antiplatelet management for ruptured intracranial aneurysms treated with stent-assisted coiling or flow diversion. Experts suggest a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor is preferred.
Area of Science:
- Neuroendovascular Therapy
- Neurosurgery
- Vascular Neurology
Background:
- Paucity of data on antiplatelet strategies for ruptured intracranial aneurysms treated with stent-assisted coiling/flow diversion.
- Need for clear management guidelines in this high-risk patient population.
Purpose of the Study:
- Identify challenges in antiplatelet management for stent-assisted coiling/flow diversion in ruptured intracranial aneurysms.
- Outline consensus-based antiplatelet management strategies.
Main Methods:
- Modified DELPHI approach utilizing an international, multidisciplinary panel of 15 neurointerventionalists.
- Iterative online questionnaires (open-ended then closed-ended) for anonymous response analysis.
- Endorsement by major international neurointerventional societies.
Main Results:
- Consensus reached that platelet function testing may not be necessary.
- Antiplatelet management for stent-assisted coiling and flow diversion can follow similar principles.
- Preferred periprocedural dual-antiplatelet regimen: intravenous aspirin and glycoprotein IIb/IIIa inhibitor, convertible to oral agents within 24 hours.
Conclusions:
- Urgent need for more robust data on antiplatelet management in this setting.
- DELPHI panel favored a periprocedural dual-antiplatelet regimen including aspirin and a glycoprotein IIb/IIIa inhibitor.
Background And Purpose:
There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies.
Materials And Methods:
The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society.
Results:
Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure.
Conclusions:
More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.
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