What is the standard antiplatelet regimen in neuro-endovascular patients?

A survey of neuro-endovascular centres in the US has found dual antiplatelet therapy with aspirin and clopidogrel to be the standard of care in patients undergoing endovascular neuro-interventional procedures. Nearly half of responding institutions use ticagrelor if clopidogrel resistance is suspected.

“Intra- and postprocedural thrombosis are major complication of aneurysmal coil embolization, stent-assisted coiling, and pipeline embolization,” the authors said. “The common but unproven practice of dual antiplatelet therapy with aspirin and a P2Y12 inhibitor in neuro-endovascular patients is inferred from the cardiology literature without large clinical trials to support it in neuro-endovascular patients.”

An electronic survey was conducted to identify practice variations surrounding the use of oral antiplatelets across neuro-endovascular centres in the US. Any practicing neuro-intensive care unit (ICU), neuro-interventional or stroke physician, pharmacist, physician assistant, or nurse practitioner was eligible to respond to the survey between June and October 2017.

Thirty-three responses were obtained during the study period. A 16-percent response rate was achieved after considering all comprehensive stroke centres in the US.

The standard-of-care antiplatelet regimen used in most institutions (82 percent) was aspirin and clopidogrel. On the other hand, four institutions utilized monotherapy (aspirin, n=2; clopidogrel, n=1; either aspirin or clopidogrel, n=1) and two institutions reported practitioner-dependent practices.

Furthermore, nearly half of the centres (48 percent) reported using ticagrelor as the primary alternative in clopidogrel nonresponders.

“Large society-wide patient registries are needed to provide data for future safety and efficacy studies,” the authors said.