Use of cangrelor in neuroendovascular interventions: real-world evidence from a single-center cohort

Neurovascular emergencies such as ruptured cerebral aneurysms and acute ischemic stroke (AIS) remain associated with high morbidity and mortality. Stent implantation has become increasingly important in their management, yet these procedures require immediate and reliable platelet inhibition. Cangrelor, an intravenous P2Y12 inhibitor with rapid onset and offset, may offer advantages compared to conventional oral or intravenous regimens.

To evaluate the efficacy and safety of cangrelor in patients with acute ischemic stroke (AIS) and in patients with cerebral aneurysms, requiring emergency stent implantation.

We retrospectively reviewed 43 consecutive patients with AIS and 24 patients with cervical and cerebral aneurysms treated between January 2021 and March 2026 who received cangrelor during emergency stenting. Indications included AIS with tandem occlusion (n = 35) or intracranial stenosis requiring acute stenting (n = 8), ruptured (n = 17) and acutely symptomatic unruptured (n = 2) aneurysms requiring flow-diverter, stent-assisted coiling (n = 3) or bailout stenting (n = 1) and one extracranial carotid pseudoaneurysm treated with a covered stent. All patients received full dose of cangrelor (bolus 30 µg/kg followed by infusion 4 µg/kg/min for 12-24 h), transitioned to aspirin and ticagrelor. Primary efficacy endpoint was 24-hour stent patency; primary safety endpoint was hemorrhagic complications.

Mean age was 66.3 ± 14.1 years for the AIS subgroup and 63.1 ± 16.2 years for the aneurysm subgroup; in AIS cohort 31 patients were male; in cerebral aneurysm 9 patients were male. Hypertension was the most common comorbidity (62.9% in AIS; 81.3% in aneurysms). In the AIS subgroup, median NIHSS at admission was 12; in the aneurysm subgroup median Hunt-Hess grade for SAH was 1. At 24 h, stent patency was 97.7% (n = 42/43) in the AIS subgroup and 100% (n = 23/23) in the aneurysm subgroup. Hemorrhagic complications occurred in 7.0% (n = 3/43) of AIS patients and 4.3% (n = 1/23) of aneurysm patients, the latter being related to intraprocedural aneurysmal perforation rather than treatment-induced bleeding. Technical success was achieved in almost all cases (TICI 2c/3 n = 40; 97.6%; aneurysm exclusion n = 24; 100%); a good functional outcome (mRS ≤ 2) at discharge was obtained in n = 15/32 (46.9%) in AIS subgroup and in n = 19/24 (79.2%) in aneurysm subgroup. Overall mortality was 9.1% (n = 6/66).

Although this study has an exploratory nature, cangrelor provided effective and safe peri-procedural platelet inhibition, ensuring high rates of stent patency and low rates of bleeding in both AIS and aneurysm-related populations requiring emergency stenting. Given the clinical heterogeneity between these cohorts, these preliminary observations should be interpreted separately and considered hypothesis-generating. Larger prospective studies are needed to confirm these findings.