title: Delayed ischemic stroke after stent-assisted coil placement in cerebral aneurysm: characteristics and optimal duration of preventative dual antiplatelet therapy.
abstract: OBJECTIVE
  To evaluate characteristics of delayed ischemic stroke after stent-assisted coil placement in cerebral aneurysms and to determine the optimal duration of dual antiplatelet therapy for its prevention.
  
  
  METHODS
  This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Of 1579 patients with 1661 aneurysms, 395 patients (25.0%) with 403 aneurysms (24.3%) treated with stent-assisted coil placement were included and assigned to groups stratified as early (126 patients [31.9%]; 3 months of coil placement), midterm (160 patients [40.5%]; 6 months), or late (109 patients [27.6%]; ≥ 9 months), according to the time points of switching dual antiplatelet therapy to monotherapy from coil placement. Cumulative rates of delayed ischemic stroke in each group were calculated by using Kaplan-Meier estimates that were compared with log-rank tests. Risk factors of delayed ischemic stroke were identified by using Cox proportional hazard analysis.
  
  
  RESULTS
  Delayed ischemic stroke occurred in 3.5% of all cases (embolism, 3.0%; thrombotic occlusion, 0.5%) within 2 months following the switch. Late switch yielded no delayed ischemic stroke, unlike early (seven of 126 patients [5.6%]; P = .013) or midterm (seven of 160 patients [4.4%]; P = .028) switch. Incomplete occlusion (hazard ratio, 6.68 [95% confidence interval: 1.490, 29.900]) was identified as a risk factor.
  
  
  CONCLUSIONS
  Delayed ischemic stroke after stent-assisted coil placement is caused by embolism from or thrombotic occlusion of stent-containing vessels after switching from dual antiplatelet therapy to monotherapy. The stent-containing vessel with incomplete aneurysm occlusion presents as a long-term thromboembolic source. Therefore, dual antiplatelet therapy for more than 9 months and late switch to monotherapy are recommended for its prevention.
authors.affiliation: From the Department of Neurosurgery, Seoul National University Bundang Hospital, 300 Gumi-dong, Bungdang-gu, Seongnam, Gyeonggi 463-707, Korea (G.H., N.M.P., S.J.P., E.A.J., O.K.K.); Department of Neurosurgery, New Korea Hospital, Gimpo, Korea (J.G.K., K.S.S.); Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Korea (Y.J.L.); Department of Neuroscience, Section of Neurosurgery, Makati Medical Center, Makati, Philippines (J.B.V.); and Department of Neurosurgery, Airlangga University, Dr Sutomo General Hospital, Surabaya, Indonesia (N.S.S.).
authors.forename: Gyojun
authors.initials: G
authors.lastname: Hwang
authors.forename: Jeong Gyun
authors.initials: JG
authors.lastname: Kim
authors.forename: Kyung Sun
authors.initials: KS
authors.lastname: Song
authors.forename: Young Jin
authors.initials: YJ
authors.lastname: Lee
authors.forename: Jay Bautista
authors.initials: JB
authors.lastname: Villavicencio
authors.forename: Nur Setiawan
authors.initials: NS
authors.lastname: Suroto
authors.forename: Nam-Mi
authors.initials: NM
authors.lastname: Park
authors.forename: Soo Joo
authors.initials: SJ
authors.lastname: Park
authors.forename: Eun-A
authors.initials: EA
authors.lastname: Jeong
authors.forename: O-Ki
authors.initials: OK
authors.lastname: Kwon
mesh_terms: D001241:Aspirin / Q000008:administration & dosage*; D000077144:Clopidogrel; D004621:Embolization, Therapeutic / Q000009:adverse effects*; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage*; D012042:Registries; D012189:Retrospective Studies; D015607:Stents / Q000009:adverse effects*; D020521:Stroke / Q000209:etiology* / Q000517:prevention & control; D013988:Ticlopidine / Q000008:administration & dosage / Q000031:analogs & derivatives*; D016896:Treatment Outcome
chemical_list: D010975:Platelet Aggregation Inhibitors; D000077144:Clopidogrel; D013988:Ticlopidine; D001241:Aspirin