title: Use of thromboelastography to tailor dual-antiplatelet therapy in patients undergoing treatment of intracranial aneurysms with the Pipeline embolization device.
abstract: BACKGROUND
  Platelet function testing is controversial and not well studied in patients with neurovascular disease.
  
  
  OBJECTIVE
  To evaluate the performance of thromboelastography (TEG) as a platelet function test in neurovascular patients treated with the Pipeline embolization device (PED).
  
  
  METHODS
  A prospective protocol was instituted for platelet function testing in patients undergoing repair of intracranial aneurysms with the PED. All patients received dual antiplatelet therapy (DAT) and their response to both P2Y12 inhibitors and aspirin was quantified with TEG. Each patient's DAT induction strategy was tailored based on the percentage ADP-induced and percentage arachidonic acid-induced platelet inhibition reported by TEG. Data collected included clinical presentation, aneurysm characteristics, treatment details, and periprocedural events. Patients were followed up clinically and/or angiographically at 30 days, 6 months, and 1 year.
  
  
  RESULTS
  Thirty-four PED procedures were performed on 31 patients. TEG results altered the DAT strategy in 35% of patients. Technical success with the Pipeline placement was 100%. Two patients had minor strokes and five had transient ischemic attacks (TIAs). There have been no hemorrhagic complications. No patient had permanent neurologic deficits. Six of eight (75%) of patients with thromboembolic/TIA events were ADP-induced hyporesponders by TEG. Our 6- and 12-month angiographic occlusion rates were 78.9% and 89.5%, respectively. The 19 major branches covered by the PED that were assessed by follow-up imaging have all remained patent.
  
  
  CONCLUSIONS
  Platelet function testing with TEG altered our DAT induction strategy in a significant number of cases. No hemorrhagic or disabling thromboembolic complications were seen in this series. Future studies should compare methods of platelet function testing and, possibly, no platelet function testing in neurovascular patients undergoing flow diversion and/or stent-assisted treatment of intracranial aneurysms.
authors.affiliation: Department of Radiology, Cleveland Clinic Florida, Weston, Florida, USA Department of Neurosurgery, Cleveland Clinic Florida, Weston, Florida, USA Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA.
authors.forename: Ryan A
authors.initials: RA
authors.lastname: McTaggart
authors.affiliation: Department of Radiology, Stanford University School of Medicine, Stanford, California, USA Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Omar A
authors.initials: OA
authors.lastname: Choudhri
authors.affiliation: Department of Radiology, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Mary L
authors.initials: ML
authors.lastname: Marcellus
authors.affiliation: Department of Radiology, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Tom
authors.initials: T
authors.lastname: Brennan
authors.affiliation: Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Gary K
authors.initials: GK
authors.lastname: Steinberg
authors.affiliation: Department of Radiology, Stanford University School of Medicine, Stanford, California, USA Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Dodd
authors.affiliation: Department of Radiology, Stanford University School of Medicine, Stanford, California, USA Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Huy M
authors.initials: HM
authors.lastname: Do
authors.affiliation: Department of Radiology, Stanford University School of Medicine, Stanford, California, USA Department of Neurosurgery, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: Michael P
authors.initials: MP
authors.lastname: Marks
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001241:Aspirin / Q000008:administration & dosage / Q000494:pharmacology; D001807:Blood Vessel Prosthesis; D000077144:Clopidogrel; D004359:Drug Therapy, Combination; D004621:Embolization, Therapeutic / Q000295:instrumentation* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002532:Intracranial Aneurysm / Q000188:drug therapy / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage* / Q000494:pharmacology; D000068799:Prasugrel Hydrochloride / Q000008:administration & dosage / Q000494:pharmacology; D058921:Purinergic P2Y Receptor Antagonists / Q000008:administration & dosage* / Q000494:pharmacology; D013916:Thrombelastography / Q000379:methods* / Q000592:standards; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000494:pharmacology; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D058921:Purinergic P2Y Receptor Antagonists; D000077144:Clopidogrel; D000068799:Prasugrel Hydrochloride; D013988:Ticlopidine; D001241:Aspirin
keywords: Aneurysm; Drug; Flow Diverter; Platelets; Technique