Antiplatelet Therapy for Stent-Assisted Coil of Ruptured Middle Cerebral Artery Bifurcation Aneurysm: Is There a Right Answer?

A variety of modalities exist for treatment of cerebral aneurysms. Stent-assisted coiling is an effective option but poses a challenge regarding antiplatelet therapy. No consensus exists among neuroendovascular surgeons regarding preferred agent, dose, and timing to balance the risk of thromboembolism and hemorrhage. This is especially true in the setting of aneurysmal subarachnoid hemorrhage. We present a 66-year-old female with history of thrombocytopenia and nonalcoholic cirrhosis who presented with severe headache. Head CT demonstrated a right temporal lobe intraparenchymal hemorrhage with sylvian fissure subarachnoid hemorrhage. Cerebral angiogram showed a 1.5mm x 1.5mm right middle cerebral artery (MCA) bifurcation aneurysm. The patient underwent Y-stent coiling from the right M1 into the right M2 superior division and the right M1 into the right M2 inferior division, with a 1mm x 1cm coil. Given the patient's thrombocytopenia, only aspirin monotherapy was administered peri-procedural. Shortly thereafter, the patient developed left hemiparesis. Computed tomography angiogram (CTA) demonstrated thrombus within the stent. Thrombectomy was performed with thrombolysis in cerebral infarction (TICI) 3 revascularization and improvement to neurologic baseline. However, that evening she became acutely hypotensive, unresponsive, and ultimately expired due to hemorrhagic cause. Antiaggregate therapy among neuroendovascular procedures is debated with no clear standard of care. This case highlights the difficult decisions that must be made to balance the risks associated with the use of antiplatelets with ruptured aneurysms.