Antiplatelet Management for Stent-Assisted Coiling and Flow Diversion of Ruptured Intracranial Aneurysms: A DELPHI Consensus Statement

J.M. Ospel; P. Brouwer; F. Dorn; A. Arthur; M.E. Jensen; R. Nogueira; R. Chapot; F. Albuquerque; C. Majoie; M. Jayaraman; A. Taylor; J. Liu; J. Fiehler; N. Sakai; K. Orlov; D. Kallmes; J.F. Fraser; L. Thibault; M. Goyal

doi:10.3174/ajnr.A6814

Abstract

BACKGROUND AND PURPOSE: There is a paucity of data regarding antiplatelet management strategies in the setting of stent-assisted coiling/flow diversion for ruptured intracranial aneurysms. This study aimed to identify current challenges in antiplatelet management during stent-assisted coiling/flow diversion for ruptured intracranial aneurysms and to outline possible antiplatelet management strategies.

MATERIALS AND METHODS: The modified DELPHI approach with an on-line questionnaire was sent in several iterations to an international, multidisciplinary panel of 15 neurointerventionalists. The first round consisted of open-ended questions, followed by closed-ended questions in the subsequent rounds. Responses were analyzed in an anonymous fashion and summarized in the final manuscript draft. The statement received endorsement from the World Federation of Interventional and Therapeutic Neuroradiology, the Japanese Society for Neuroendovascular Therapy, and the Chinese Neurosurgical Society.

RESULTS: Data were collected from December 9, 2019, to March 13, 2020. Panel members achieved consensus that platelet function testing may not be necessary and that antiplatelet management for stent-assisted coiling and flow diversion of ruptured intracranial aneurysms can follow the same principles. Preprocedural placement of a ventricular drain was thought to be beneficial in cases with a high risk of hydrocephalus. A periprocedural dual, intravenous, antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor was preferred as a standard approach. The panel agreed that intravenous medication can be converted to oral aspirin and an oral P2Y12 inhibitor within 24 hours after the procedure.

CONCLUSIONS: More and better data on antiplatelet management of patients with ruptured intracranial aneurysms undergoing stent-assisted coiling or flow diversion are urgently needed. Panel members in this DELPHI consensus study preferred a periprocedural dual-antiplatelet regimen with aspirin and a glycoprotein IIb/IIIa inhibitor.

ABBREVIATION:

GPIIb/IIIa: glycoprotein IIb/IIIa receptor

Footnotes

Disclosures: Johanna M. Ospel—UNRELATED: Grants/Grants Pending: Julia Bangerter Rhyner Foundation, University of Basel Research Foundation, Freiwiliige Akademische Gesellschaft Basel, Comments: research scholarships. Patrick Brouwer—UNRELATED: Consultancy: Cerenovus; Payment for Lectures Including Service on Speakers Bureaus: Cerenovus. Franziska Dorn—UNRELATED: Consultancy: Cerus Endovascular, phenox, Balt; Payment for Lectures Including Service on Speakers Bureaus: speakers honoraria from Cerenovus and Acandis. Adam Arthur—UNRELATED: Consultancy: Balt, Cerenovus, Medtronic, MicroVention, Penumbra, Siemens, Stryker*; Stock/Stock Options: Bendit, Cerebrotech, EndoStream, Magneto, Marblehead Medical, Neurogami, Serenity, Synchron, Triad Medical, Vascular Simulations. Mary E. Jensen—UNRELATED: Employment: University of Virginia Health System. Raul Nogueira—OTHER RELATIONSHIPS: Consulting Fees: Anaconda, Biogen, Cerenovus, Genentech, Imperative Care, Medtronic, phenox, Prolong Pharmaceuticals, Stryker Neurovascular; Stock/Stock Options: advisory roles with Astrocyte Pharmaceuticals, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-Ai, and Perfuze. Rene Chapot—UNRELATED: Payment for Lectures Including Service on Speakers Bureaus: Balt, Medtronic, MicroVention, Siemens, Stryker*; Travel/Accommodations/Meeting Expenses Unrelated to Activities Listed: Boston, Balt, MicroVention, Rapid Medical, Siemens. Charles Majoie—UNRELATED: Grants/Grants Pending: European Commission, Dutch Heart Foundation, Stryker*; Stock/Stock Options: Nico.lab (modest), Comments: a company that focuses on the use of artificial intelligence for medical imaging analysis. Mahesh Jayaraman—UNRELATED: Consultancy: Medtronic, Comments: speaking for stroke systems of care at ISC 2018. Allan Taylor—UNRELATED: Employment: Groote Schuur Hospital, Comments: full-time employment with a public hospital; Expert Testimony: defense and prosecuting attorneys, Comments: I provide expert testimony in neuromuscular cases for 1 to 2 matters per year; Other: private practice, Comments: I have a limited private practice for patients with neuromuscular disease. Jens Fiehler—UNRELATED: Consultancy: Acandis, Cerenovus, Medtronic, MicroVention, Stryker, Penumbra; Grants/Grants Pending: Acandis, Cerenovus, Medtronic, MicroVention, Stryker*; Stock/Stock Options: Tegus; OTHER RELATIONSHIPS: Eppdata CEO. Nobuyuki Sakai—UNRELATED: Grants/Grants Pending: Terumo, Medtronic, Comments: Modest*; Payment for Lectures Including Service on Speakers Bureaus: Biomedical Solutions, Stryker, Terumo.* Mayank Goyal—UNRELATED: Consultancy: Stryker, Medtronic, MicroVention, Mentice, Comments: advice on acute stroke intervention; Grants/Grants Pending: Medtronic, Stryker, Cerenovus, Comments: unrestricted research grants to University of Calgary*; Patents (Planned, Pending or Issued): GE Healthcare, Comments: licensing agreement: Systems of Acute Stroke Diagnosis; Royalties: GE Healthcare. Kirill Orlov—UNRELATED: Consultancy: Medtronic, MicroVention. Justin Fraser—UNRELATED: Board Membership: Cerelux; Consultancy: Medtronic, Penumbra, Stream; Grants/Grants Pending: American Heart Association, University of Kentucky; Stock/Stock Options: Fawkes Biotechnology. David Kallmes—UNRELATED: Grants/Grants Pending: MicroVention, NeuroSigma, Medtronic, Comments: funding for preclinical research*; Patents (Planned, Pending or Issued): Mayo Clinic, Comments: patent for protection device*; Stock/Stock Options: Marblehead Medical, Superior Medical Experts. *Money paid to the institution.