Managing thrombosis risk in flow diversion: A review of antiplatelet approaches

Abstract

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.