Bell Hayden, Steinfort Brendan, Pasalic Leonardo, Dexter Mark
Neurosurgery, Westmead Hospital, Sydney, New South Wales, Australia
Neurosurgery, Westmead Hospital, Sydney, New South Wales, Australia.
BMJ Case Rep. 2020 Mar 12;13(3):e233947. doi: 10.1136/bcr-2019-233947.
A patient undergoes intracranial stent insertion for stent-assisted coiling of a basilar tip aneurysm and left middle cerebral artery aneurysm. A flow diverting stent is also placed across an anterior communicating artery aneurysm. Prior to the procedure, the patient takes dual antiplatelet medications, being aspirin and clopidogrel. Because of the concern regarding in-stent thrombus and thromboembolic complications related to intracranial stenting and the high rate of clopidogrel resistance, preoperative platelet function testing (PFT) was undertaken to ensure platelet inhibition. In this case, PFT was performed on a platelet function analyser which demonstrated platelet inhibition. Ten days following the procedure, the patient represented with thromboembolic stroke. Repeat PFT performed with whole blood impedance aggregometry and despite full medication compliance demonstrated clopidogrel resistance. Clopidogrel was then ceased and prasugrel commenced. This case demonstrates the importance of appropriate platelet inhibition in patients with intracranial stents and the controversy surrounding PFT.
一名患者接受颅内支架置入术，用于基底动脉尖动脉瘤和左大脑中动脉动脉瘤的支架辅助弹簧圈栓塞治疗。还在一条前交通动脉动脉瘤处放置了血流导向支架。术前，患者服用阿司匹林和氯吡格雷这两种双联抗血小板药物。由于担心与颅内支架置入相关的支架内血栓形成和血栓栓塞并发症以及氯吡格雷抵抗的高发生率，进行了术前血小板功能检测（PFT）以确保血小板受到抑制。在本病例中，使用血小板功能分析仪进行了PFT，结果显示血小板受到抑制。术后十天，患者出现血栓栓塞性中风。采用全血阻抗聚集法进行重复PFT，尽管患者完全遵医嘱用药，但仍显示出氯吡格雷抵抗。随后停用氯吡格雷，开始使用普拉格雷。本病例证明了颅内支架置入患者中适当血小板抑制的重要性以及围绕PFT的争议。
