Hemorrhagic complications after prasugrel (Effient) therapy for vascular neurointerventional procedures

J Neurointerv Surg. 2013 Jul;5(4):337-43. doi: 10.1136/neurintsurg-2012-010334. Epub 2012 May 3.


Introduction: Dual antiplatelet therapy (DAPT) with aspirin and a thienopyridine (eg, clopidogrel) prevents stent related thromboembolic events in cardiac patients and is frequently utilized during neurointerventional surgery. However, recent data suggest that many patients exhibit clopidogrel resistance. Prasugrel-a newer thienopyridine-lowers the rate of cardiac stent thromboses in clopidogrel non-responders but a paucity of data exist regarding its safety and efficacy in neurointerventional surgery.

Methods: All patients undergoing neurointerventional surgery by a single interventionalist (CJM) over a 20 month period were retrospectively identified. Charts were reviewed for pre- and post-procedural DAPT regimens, pre-procedural coagulation parameters and procedural complications.

Results: 76 patients received pre- and post-procedural DAPT for endovascular treatment of an intracerebral aneurysm, dural arteriovenous fistula or intra/extracranial arterial stenosis. 51 patients underwent 55 total procedures and were treated with aspirin/clopidogrel; 25 patients underwent 31 total procedures and were treated with aspirin/prasugrel. Those patients who received aspirin/prasugrel DAPT were identified pre-procedurally to be clopidogrel non-responders. Both treatment groups had a similar percentage of patients undergoing aneurysm coiling, stent assisted aneurysm coiling, aneurysm Onyx embolization, aneurysm pipeline embolization device treatment, extra/intracranial carotid artery angioplasty and stenting, and dural arteriovenous fistula coil embolization. A total of eight (9.3%) hemorrhagic complications were observed, two (3.6%) in the aspirin/clopidogrel group and six (19.4%) in the aspirin/prasugrel group (p=0.02). No differences were noted in hemorrhage rates for each procedure between treatment groups, nor were there any differences in thrombotic complications between groups.

Conclusion: Our results suggest that DAPT with aspirin/prasugrel may predispose to a higher risk of hemorrhage during neurointerventional surgery compared with DAPT with aspirin/clopidogrel.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Aged
  • Cerebral Hemorrhage / diagnostic imaging*
  • Cerebral Hemorrhage / etiology*
  • Embolization, Therapeutic / adverse effects*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Neuroprotective Agents / adverse effects
  • Piperazines / adverse effects*
  • Prasugrel Hydrochloride
  • Purinergic P2X Receptor Antagonists / adverse effects*
  • Radiography
  • Retrospective Studies
  • Thiophenes / adverse effects*


  • Neuroprotective Agents
  • Piperazines
  • Purinergic P2X Receptor Antagonists
  • Thiophenes
  • Prasugrel Hydrochloride