Ruptured cerebral aneurysm treatment with flow diversion: a single practice series and proposed antiplatelet protocol for loading as well as partial tapering for invasive procedures
Arjun Agrawal, Akash S Agrawal, Samuel Zen Kai Yap, Munasib Hossain, Kelly Hoonhout, Andrew DeNardo, Krishna Amuluru, Charles Kulwin, Troy Payner, Kushal J Shah, Vivek Kumar Agrawal, Daniel H SahleinBackground
Flow diversion is increasingly used for ruptured intracranial aneurysms not well suited for clipping or endosaccular treatment, but dual antiplatelet therapy (DAPT) complicates postprocedure management. We introduce a DAPT protocol for loading and partial tapering for invasive procedures post-embolisation.
Methods
This is a retrospective consecutive single-practice series of acutely ruptured intracranial aneurysms treated primarily with flow diversion (2015–2024). Part way through this time period, we instituted a DAPT loading protocol (90 mg ticagrelor at 04:00 and another dose of 90 mg ticagrelor with 81 mg aspirin at 06:00 for an 08:00 procedure, followed by 60 mg ticagrelor two times per day with 81 mg aspirin daily thereafter) as well as a partial-taper protocol for invasive procedures (skipping a full day of ticagrelor and a morning dose the following day, continuing 81 mg aspirin daily, and doing all procedures between 10:00 and 12:00 on day 2). The primary endpoint was modified Rankin Scale 0–2 at last follow-up.
Results
37 patients were included (10 preprotocol, 27 postprotocol). Favourable outcome was achieved in 24/37 (64.9%) and complete occlusion was seen in all patients with imaging follow-up (28/28). Major complications occurred in 40% (4/10) patients before vs 11% (3/27) after protocol adoption (p=0.048), while invasive procedures rose from 0.5/patient to 1.3/patient. Protocol use independently predicted favourable outcome (OR 10.4, p=0.041).
Conclusions
A ticagrelor-based loading and partial-taper strategy permitted substantially more post-implant invasive procedures with fewer major complications, supporting flow diversion in the setting of aneurysmal subarachnoid haemorrhage.