Safety and Efficacy of Prasugrel with Endovascular Treatment for Unruptured Cerebral Aneurysm

Objective: Recently, dual-antiplatelet therapy (DAPT) including clopidogrel (CLP) with endovascular treatment for unruptured cerebral aneurysm has been widely accepted. However, patients who are poor metabolizers of CLP (CLP-PMs) are more frequent in East Asians than in Caucasians, and an adequate antiplatelet effect may not be achieved with a normal dose in such patients. Prasugrel, which is a novel thienopyridine antiplatelet drug that is less likely to be poorly metabolized than CLP, is used widely for percutaneous coronary intervention, but its efficacy and safety with neuroendovascular treatment have not been elucidated. From this point of view, the purpose of this study was to elucidate the safety and efficacy of prasugrel with endovascular treatment for unruptured cerebral aneurysm. Methods: We investigated 108 consecutive patients with an unruptured cerebral aneurysm who underwent endovascular treatment from March 2015 to January 2016 in our hospital. All patients received DAPT with 100 mg aspirin and 75 mg CLP daily, and antiplatelet function was evaluated by VerifyNow (Accumetrics, San Diego, CA, USA). In patients with P2Y12 reaction units (PRU) over 230, prasugrel was administered with a loading dose of 20 mg and a maintenance dose of 3.75 mg daily. Results: Prasugrel was administered to 12 patients in our series. Of these patients, the mean age was 63.1 +- 13.0 years, and the mean PRU was 272 +- 20. Eleven patients received endovascular treatment with intracranial stents, of which four patients received treatment with flow diverters. The mean observational period was 5 - 13 months (median: 6.5), and no symptomatic hemorrhagic and ischemic complications occurred. Mean PRU was decreased to 159 +- 63 in the six patients in which PRU were re-examined. Conclusion: Prasugrel is safe and effective with endovascular treatment for unruptured cerebral aneurysm in CLP-PMs.