Geisbush Thomas R, Pulli Benjamin, Wolman Dylan N, Pendharkar Arjun V, Telischak Nicholas A
Stanford Hospital and Clinics, 300 Pasteur Drive, Stanford 94305, USA.
Pacific Neuroscience Institute, 501 S Buena Vista Street, Burbank 91505, USA.
Radiol Case Rep. 2022 Aug 27;17(11):4075-4078. doi: 10.1016/j.radcr.2022.07.091. eCollection 2022 Nov.
Dual antiplatelet therapy (DAPT) is a management cornerstone for intracranial aneurysms treated with flow diversion. However, combined dual antiplatelet plus anticoagulation (triple therapy) can be indicated in some patients with important associated risks. Here we present the case of a 72-year-old woman with prior history of subarachnoid hemorrhage who was started on triple therapy (enoxaparin and DAPT) following successful flow diversion of an enlarging but unruptured left fetal posterior communicating artery aneurysm. Her post-procedural course was complicated by in-stent thrombosis in the setting of a missed ticagrelor dose and subsequent development of deep venous thrombosis and pulmonary embolism. An early follow-up angiogram confirmed occlusion of the aneurysm. However, after initiation of triple therapy, the aneurysm partially recanalized and her symptoms recurred. Subsequent discontinuation of enoxaparin lead to prompt aneurysm re-occlusion. To our knowledge, this is the first reported instance of confirmed intra-aneurysmal thrombolysis in a successfully treated aneurysm after triple therapy initiation.
双重抗血小板治疗（DAPT）是血流导向治疗颅内动脉瘤的管理基石。然而，在一些有重要相关风险的患者中，可采用双重抗血小板联合抗凝治疗（三联疗法）。在此，我们报告一例72岁女性患者，既往有蛛网膜下腔出血病史，在成功对一枚扩大但未破裂的左侧胎儿型后交通动脉瘤进行血流导向治疗后，开始接受三联疗法（依诺肝素和DAPT）。在漏服替格瑞洛剂量的情况下，她术后出现支架内血栓形成，并随后发生深静脉血栓和肺栓塞，导致病程复杂化。早期随访血管造影证实动脉瘤闭塞。然而，在开始三联疗法后，动脉瘤部分再通，症状复发。随后停用依诺肝素后，动脉瘤迅速再次闭塞。据我们所知，这是首次报道在开始三联疗法后，成功治疗的动脉瘤中出现确诊的瘤内溶栓情况。
