Considerations for Antiplatelet Management of Carotid Stenting in the Setting of Mechanical Thrombectomy: A Delphi Consensus Statement

BACKGROUND AND PURPOSE

There are only few data and lack of consensus regarding antiplatelet management for carotid stent placement in the setting of endovascular stroke treatment. We aimed to develop a consensus-based algorithm for antiplatelet management in acute ischemic stroke patients undergoing endovascular treatment and simultaneous emergent carotid stent placement.

MATERIALS AND METHODS

We performed a literature search and a modified Delphi approach used Web-based questionnaires that were sent in several iterations to an international multidisciplinary panel of 19 neurointerventionalists from 7 countries. The first round included open-ended questions and formed the basis for subsequent rounds, in which closed-ended questions were used. Participants continuously received feedback on the results from previous rounds. Consensus was defined as agreement of ≥70% for binary questions and agreement of ≥50% for questions with >2 answer options. The results of the Delphi process were then summarized in a draft manuscript that was circulated among the panel members for feedback.

RESULTS

A total of 5 Delphi rounds were performed. Panel members preferred a single intravenous aspirin bolus or, in jurisdictions in which intravenous aspirin is not available, a glycoprotein IIb/IIIa receptor inhibitor as intraprocedural antiplatelet regimen and a combination therapy of oral aspirin and a P2Y12 inhibitor in the postprocedural period. There was no consensus on the role of platelet function testing in the postprocedural period.

CONCLUSIONS

More and better data on antiplatelet management for carotid stent placement in the setting of endovascular treatment are urgently needed. Panel members preferred intravenous aspirin or, alternatively, a glycoprotein IIb/IIIa receptor inhibitor as an intraprocedural antiplatelet agent, followed by a dual oral regimen of aspirin and a P2Y12 inhibitor in the postprocedural period.

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

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.

New Detected Aneurysms on Follow-Up Screening in Patients With Previously Clipped Intracranial Aneurysms

Background and Purpose— Patients with a history of aneurysmal subarachnoid hemorrhage may have aneurysms on screening several years after the hemorrhage. For determining the benefits of follow-up screening, it is important to know whether these aneurysms have developed after the hemorrhage or are visible in retrospect, and if so, whether the size has increased.

Methods— Aneurysms were categorized into de novo aneurysms and aneurysms visible in retrospect (already present) with increased or stable size. We studied aneurysm characteristics for these 3 categories: the relation between aneurysm development or enlargement and duration of follow up and the relation between enlargement and initial size of the aneurysm.

Results— In 87 of 495 patients (17.6%), aneurysms were detected; for 51 of these patients with 62 aneurysms, the original catheter or computed tomographic angiogram was available for comparison. Of the 62 aneurysms, 19 were de novo and 43 were visible in retrospect, 10 with increased size and 33 with stable size. De novo aneurysms were mainly ≤5 mm (95%) and located at the middle cerebral artery (63%). For aneurysms visible in retrospect, the most frequent location was the posterior communicating artery (21%). There was no relation between the development of de novo aneurysms or enlargement and the duration of follow-up or between enlargement and the initial size of the aneurysm.

Conclusions— Of aneurysms detected at screening, one third were de novo and two thirds were missed at the time of the initial hemorrhage. One quarter of initially small aneurysms had enlarged during follow-up.