Neurocritical Care
Combination with mechanical thrombectomy
Rescue therapy in patients having received intravenous thrombolytic
Large hemispheric infarction
Dose is not well defined.
ii.
Typically applied until thrombus has resolved
iii.
Alteplase dose less than 20 mg
Patient Case
Questions 5 and 6 pertain to the following case.
A 49-year-old woman presents to an urgent treatment center with the βworst headache of her life.β She is
sent to your emergency department, where a head CT scan reveals a diffuse SAH. The patient takes no home
medications and has an insignificant medical history other than a 20 pack-year history of smoking.
Which therapy is most appropriate to prevent ischemic complications from SAH?
On hospital day 5, the patient has reduced alertness, and her GCS score decreases by 2 points. The digital
subtraction angiography suggests cerebral vasospasm. Which treatment modality is best to initiate first?
Intracranial stents are often deployed in place of coils or to support coils for complex aneurysms.
Blood vessels are generally smaller and more tortuous.
Flow rate is lower.
Epithelialization of stent takes longer.
Dual antiplatelet therapy is typically used around the time of stent placement.
Clopidogrel (a prodrug) plus aspirin
Current evidence suggests therapy for up to 3 months (not 4 weeks like after percutaneous coronary
intervention), followed by aspirin monotherapy thereafter.
Platelet testing may be necessary in some individuals to evaluate their pharmacogenetic response
to clopidogrel.
| d. | No gold standard for platelet reactivity testing in this setting. VerifyNow is commonly used and |
|---|
measures platelet reactivity units (PRU) for aspirin and P2Y12 inhibitors.
Some patients may not respond to clopidogrel (up to 30%), and additional loading doses and
increased maintenance doses are not effective.
Ticagrelor may play a role in patients with a variable response to clopidogrel (must be used in
combination with aspirin less than 100 mg) (Neurocrit Care 2024;40:262-71).
Prasugrel (a prodrug) is not recommended (unless absolutely necessary) in patients with high
on-treatment platelet reactivity (e.g. clopidogrel non-responders) because of warnings about use
in patients with a history of stroke β Increased bleeding. Reduced doses (2.5β5 mg) have been
reported with some success in preventing thrombosis without excessive bleeding.