title: Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures.
abstract: BACKGROUND
  Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine (eg, clopidogrel) prevents stent related thromboembolic events in cardiac patients and is frequently utilized during neurointerventional surgery. However, recent data suggest that many patients exhibit clopidogrel resistance. Prasugrel-a newer thienopyridine-lowers the rate of cardiac stent thromboses in clopidogrel non-responders but a paucity of data exist regarding its safety and efficacy in neurointerventional surgery.
  
  
  METHODS
  All patients undergoing neurointerventional surgery by a single interventionalist (CJM) over a 20 month period were retrospectively identified. Charts were reviewed for pre- and post-procedural DAPT regimens, pre-procedural coagulation parameters and procedural complications.
  
  
  RESULTS
  76 patients received pre- and post-procedural DAPT for endovascular treatment of an intracerebral aneurysm, dural arteriovenous fistula or intra/extracranial arterial stenosis. 51 patients underwent 55 total procedures and were treated with aspirin/clopidogrel; 25 patients underwent 31 total procedures and were treated with aspirin/prasugrel. Those patients who received aspirin/prasugrel DAPT were identified pre-procedurally to be clopidogrel non-responders. Both treatment groups had a similar percentage of patients undergoing aneurysm coiling, stent assisted aneurysm coiling, aneurysm Onyx embolization, aneurysm pipeline embolization device treatment, extra/intracranial carotid artery angioplasty and stenting, and dural arteriovenous fistula coil embolization. A total of eight (9.3%) hemorrhagic complications were observed, two (3.6%) in the aspirin/clopidogrel group and six (19.4%) in the aspirin/prasugrel group (p=0.02). No differences were noted in hemorrhage rates for each procedure between treatment groups, nor were there any differences in thrombotic complications between groups.
  
  
  CONCLUSIONS
  Our results suggest that DAPT with aspirin/prasugrel may predispose to a higher risk of hemorrhage during neurointerventional surgery compared with DAPT with aspirin/clopidogrel.
authors.affiliation: Department of Neurological Surgery, Washington University School of Medicine, St Louis, Missouri, USA.
authors.forename: S Hassan
authors.initials: SH
authors.lastname: Akbari
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
authors.forename: Yasha
authors.initials: Y
authors.lastname: Kadkhodayan
authors.forename: Dewitte T
authors.initials: DT
authors.lastname: Cross
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Moran
mesh_terms: D000328:Adult; D000368:Aged; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging* / Q000209:etiology*; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018696:Neuroprotective Agents / Q000009:adverse effects; D010879:Piperazines / Q000009:adverse effects*; D000068799:Prasugrel Hydrochloride; D058920:Purinergic P2X Receptor Antagonists / Q000009:adverse effects*; D011859:Radiography; D012189:Retrospective Studies; D013876:Thiophenes / Q000009:adverse effects*
chemical_list: D018696:Neuroprotective Agents; D010879:Piperazines; D058920:Purinergic P2X Receptor Antagonists; D013876:Thiophenes; D000068799:Prasugrel Hydrochloride