Toma Aureliana, Essibayi Muhammed Amir, Osama Mahmoud, Karandish Alireza, Dmytriw Adam A, Altschul David
Department of Radiology, Montefiore Medical Center, Albert Einstein College of Medicine, USA.
Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, USA.
Neuroradiol J. 2025 Jan 8:19714009251313515. doi: 10.1177/19714009251313515.
Flow diversion is a transformative approach in neurointerventional surgery for intracranial aneurysms that relies heavily on effective antiplatelet therapy. The ideal approach, including the timing of treatment, the use of dual antiplatelet therapy (DAPT), and the number of flow-diverter devices to use, remains unknown. DAPT, which combines aspirin with a thienopyridine like clopidogrel, prasugrel, or ticagrelor, is the standard regimen, balancing thromboembolic protection and hemorrhagic risk. The variable response to clopidogrel, influenced by genetic polymorphisms, necessitates personalized treatment strategies. Alternatives like prasugrel and ticagrelor provide superior efficacy in specific scenarios but require careful consideration of bleeding risks and costs. Platelet function testing plays a critical role in tailoring antiplatelet regimens for patients undergoing flow diversion for intracranial aneurysms. Special considerations were made for ruptured aneurysms, and the implications of the extensive metallic surface of flow diverters on platelet activation were noted. Emerging technologies such as drug-eluting flow diverters and reversal agents for P2Y12 inhibitors suggest a potential shift toward more refined antiplatelet strategies in the future. Personalized medication that is compatible with the stent structure and metal is essential for optimizing patient outcomes in cerebral flow diversion procedures. Ongoing research and multidisciplinary collaboration will be key in refining these strategies and enhancing the safety and efficacy of neurointerventional treatments.
血流导向是颅内动脉瘤神经介入手术中的一种变革性方法，严重依赖有效的抗血小板治疗。理想的方法，包括治疗时机、双联抗血小板治疗（DAPT）的使用以及血流导向装置的使用数量，仍然未知。DAPT将阿司匹林与氯吡格雷、普拉格雷或替格瑞洛等噻吩并吡啶类药物联合使用，是标准方案，可平衡血栓栓塞保护和出血风险。受基因多态性影响，对氯吡格雷的反应存在差异，因此需要个性化治疗策略。普拉格雷和替格瑞洛等替代药物在特定情况下具有更高的疗效，但需要仔细考虑出血风险和成本。血小板功能检测在为接受颅内动脉瘤血流导向治疗的患者制定抗血小板方案时起着关键作用。对破裂动脉瘤进行了特殊考虑，并注意到血流导向装置广泛的金属表面对血小板激活的影响。药物洗脱血流导向装置和P2Y12抑制剂逆转剂等新兴技术表明，未来可能会转向更精细的抗血小板策略。与支架结构和金属兼容的个性化药物对于优化脑血流导向手术的患者预后至关重要。正在进行的研究和多学科合作将是完善这些策略以及提高神经介入治疗安全性和有效性的关键。
