Department of Internal Medicine, Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa, USA.
J Neurosurg. 2012 Nov;117(5):929-33. doi: 10.3171/2012.8.JNS12185. Epub 2012 Sep 7.
The optimal antiplatelet medication protocol for prevention of thrombotic complications after stent-assisted coil embolization of cerebral aneurysms is unclear. Early cessation of antiplatelet agents may be associated with an increased risk of cerebral ischemic events. In this study, the authors assess the incidence of stroke or transient ischemic attack (TIA) following discontinuation of a 6-week course of clopidogrel in patients with cerebral aneurysms treated with stent-assisted techniques.
A retrospective review was conducted in all patients with cerebral aneurysms undergoing stent-assisted coil embolization or stent-in-stent flow diversion at the University of Iowa during a 24-month period. The antiplatelet protocol was 81 mg aspirin and 75 mg clopidogrel daily for 6 weeks, followed by 325 mg aspirin daily indefinitely. The incidence of stroke or TIA was determined by a retrospective review of medical records generated during a 3-month period following discontinuation of clopidogrel.
A total of 154 patients underwent aneurysm treatment with stent techniques during this interval. Documentation of neurological follow-up 3 months after discontinuation of a 6-week clopidogrel treatment was available in 121 (78.6%) of 154 patients. Of these 121 patients, 114 were treated with stent-assisted coil embolization and 7 with stent-in-stent flow diversion. Six patients (5%) suffered an ischemic event after cessation of clopidogrel, with 2 events occurring within the first 2 weeks. Specifically, the rate of ischemic events was 5 (4.3%) of 114 in the "stent-coil" treatment group and 1 (14.3%) of 7 in the stent-in-stent group. Treatment had been performed in the setting of a subarachnoid hemorrhage in 1 patient. Atypical aneurysm features and technical factors predisposing to thrombotic events were found in all but one of these patients. Similarly, cardiovascular risk factors were present in 5 of the 6 patients in whom ischemic events developed after clopidogrel discontinuation.
Clopidogrel discontinuation is associated with a 5% risk of ischemic events in patients treated with stent techniques. Any stroke related to clopidogrel discontinuation is avoidable, and longer treatment is therefore clearly necessary. Patients with cardiovascular risk factors, high-risk aneurysm features, and those undergoing stent-in-stent flow diversion might benefit the most from longer clopidogrel therapy.
对于接受支架辅助弹簧圈栓塞治疗的颅内动脉瘤患者，预防血栓并发症的最佳抗血小板药物方案尚不清楚。早期停止使用抗血小板药物可能会增加发生脑缺血事件的风险。在这项研究中，作者评估了在接受支架辅助技术治疗的颅内动脉瘤患者中停止使用氯吡格雷 6 周疗程后中风或短暂性脑缺血发作（TIA）的发生率。
对在 24 个月期间在爱荷华大学接受支架辅助弹簧圈栓塞或支架内支架血流分流术治疗的所有颅内动脉瘤患者进行了回顾性分析。抗血小板方案为每天 81 毫克阿司匹林和 75 毫克氯吡格雷 6 周，然后每天服用 325 毫克阿司匹林。通过回顾性分析停用氯吡格雷后 3 个月期间的病历确定中风或 TIA 的发生率。
在此期间，共有 154 例患者接受了支架技术治疗动脉瘤。在 154 例患者中有 121 例（78.6%）可获得停用氯吡格雷 6 周治疗后 3 个月的神经随访记录。在这 121 例患者中，114 例接受了支架辅助弹簧圈栓塞治疗，7 例接受了支架内支架血流分流术。在停用氯吡格雷后，有 6 例（5%）发生缺血性事件，其中 2 例发生在最初的 2 周内。具体来说，在“支架线圈”治疗组中，缺血性事件的发生率为 5（4.3%）例，而在支架内支架组中，缺血性事件的发生率为 1（14.3%）例。在 1 例患者中，治疗是在蛛网膜下腔出血的情况下进行的。在所有这些患者中，除 1 例患者外，均存在导致血栓形成事件的非典型动脉瘤特征和技术因素。同样，在停用氯吡格雷后发生缺血性事件的 6 例患者中，有 5 例存在心血管危险因素。
在接受支架技术治疗的患者中，停用氯吡格雷后缺血性事件的风险为 5%。任何与停用氯吡格雷相关的中风都是可以避免的，因此显然需要更长的治疗时间。有心血管危险因素、高危动脉瘤特征和接受支架内支架血流分流术的患者可能从更长时间的氯吡格雷治疗中获益最大。
