Abstract
A 66-year-old female patient presented to the referring hospital with a right hemispheric transient ischemic attack (TIA). During the workup of the TIA, an incidental paraophthalmic aneurysm of the right internal carotid artery was found. This aneurysm was treated with intra- and extrasaccular flow diversion. Dual platelet inhibition was achieved using 1× 100 mg ASA and 2× 90 mg ticagrelor PO daily. Three days after the treatment, the patient complained of severe headaches. MRI showed a minor subarachnoid hemorrhage (SAH) in the cortical sulci over both hemispheres. Multiplate and VerifyNow analyses showed excessive inhibition of platelet function. In order to reverse this hyperresponse, the evening dosage of 90 mg ticagrelor was withdrawn on the day following the diagnosis of the SAH. The next morning, the patient had a left hemiparesis, a severe dysarthria and fixed conjugate gaze deviation. MRI revealed a thrombotic occlusion of the right ICA at the site of the implanted flow diverter. The subsequent DSA showed reduced collateral flow from the left ICA to the right via the anterior communicating artery (AcomA) with a significant delay in right venous phase opacification. Multiplate and VerifyNow analyses confirmed inadequate P2Y12 receptor blockade only 24 h after the last dose of 90 mg ticagrelor. Due to the short duration of action of ticagrelor, the single omitted dose was sufficient to cause the recently implanted flow diverter to thrombose. The occluded right ICA was recanalized using aspiration thrombectomy and the deployment of a second p64 flow diverter. The patient recovered completely and follow-up DSA examinations confirmed the continued exclusion of the paraophthalmic aneurysm from the circulation. The pharmacokinetic properties of ticagrelor including its short duration of action are the main topic of this chapter.
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References
Bender MT, Zarrin DA, Campos JK, Jiang B, Chandra A, Vo CD, Caplan JM, Huang J, Tamargo RJ, Lin LM, Colby GP, Coon AL. Precision of VerifyNow P2Y12 assessment of clopidogrel response in patients undergoing cerebral aneurysm flow diversion. Neurosurgery. 2018. https://doi.org/10.1093/neuros/nyy395.
Buchanan A, Newton P, Pehrsson S, Inghardt T, Antonsson T, Svensson P, Sjögren T, Öster L, Janefeldt A, Sandinge AS, Keyes F, Austin M, Spooner J, Gennemark P, Penney M, Howells G, Vaughan T, Nylander S. Structural and functional characterization of a specific antidote for ticagrelor. Blood. 2015;125(22):3484–90. https://doi.org/10.1182/blood-2015-01-622928.
Can A, Rudy RF, Castro VM, Yu S, Dligach D, Finan S, Gainer V, Shadick NA, Savova G, Murphy S, Cai T, Weiss ST, Du R. Association between aspirin dose and subarachnoid hemorrhage from saccular aneurysms: a case-control study. Neurology. 2018;91(12):e1175–81. https://doi.org/10.1212/WNL.0000000000006200.
Cea Soriano L, Gaist D, Soriano-Gabarró M, Bromley S, García Rodríguez LA. Low-dose aspirin and risk of intracranial bleeds: an observational study in UK general practice. Neurology. 2017;89(22):2280–7. https://doi.org/10.1212/WNL.0000000000004694.
Cuisset T, Frere C, Quilici J, Uhry S, Alessi MC, Bonnet JL. Post-PCI fatal bleeding in aspirin and clopidogrel hyper responder: shifting from antiplatelet resistance to bleeding risk assessment? Int J Cardiol. 2010;138(2):212–3. https://doi.org/10.1016/j.ijcard.2008.06.044.
Easton JD, Aunes M, Albers GW, Amarenco P, Bokelund-Singh S, Denison H, Evans SR, Held P, Jahreskog M, Jonasson J, Minematsu K, Molina CA, Wang Y, Wong KSL, Johnston SC, SOCRATES Steering Committee and Investigators. Risk for major bleeding in patients receiving ticagrelor compared with aspirin after transient ischemic attack or acute ischemic stroke in the SOCRATES study (Acute stroke or transient ischemic attack treated with aspirin or ticagrelor and patient outcomes). Circulation. 2017;136(10):907–16. https://doi.org/10.1161/CIRCULATIONAHA.117.028566.
Flechtenmacher N, Kämmerer F, Dittmer R, Budde U, Michels P, Röther J, Eckert B. Clopidogrel resistance in neurovascular stenting: correlations between light transmission aggregometry, VerifyNow, and the Multiplate. AJNR Am J Neuroradiol. 2015;36(10):1953–8. https://doi.org/10.3174/ajnr.A4388.
Frontera JA, Provencio JJ, Sehba FA, McIntyre TM, Nowacki AS, Gordon E, Weimer JM, Aledort L. The role of platelet activation and inflammation in early brain injury following subarachnoid hemorrhage. Neurocrit Care. 2017;26(1):48–57. https://doi.org/10.1007/s12028-016-0292-4.
Kremke M, Gissel MS, Jensen MJ, Thomassen SA, Jakobsen CJ. The association between a three-day ticagrelor discontinuation and perioperative bleeding complications. Eur J Cardiothorac Surg. 2018. https://doi.org/10.1093/ejcts/ezy355.
Kruger PC, Hirsh J, Bhagirath VC, Xu K, Dale B, de Vries TAC, Ginsberg JS, Eikelboom JW, Chan NC. In vitro reversal of the anti-aggregant effect of ticagrelor using untreated platelets. Thromb Haemost. 2018;118(11):1895–901. https://doi.org/10.1055/s-0038-1673381.
Lanas AI, Arroyo MT, Esteva F, Cornudella R, Hirschowitz BI, Sáinz R. Aspirin related gastrointestinal bleeders have an exaggerated bleeding time response due to aspirin use. Gut. 1996;39(5):654–60.
Ramchand P, Nyirjesy S, Frangos S, Doerfler S, Nawalinski K, Quattrone F, Ju C, Patel H, Driscoll N, Maloney-Wilensky E, Stein SC, Levine JM, Kasner SE, Kumar MA. Thromboelastography parameter predicts outcome after subarachnoid hemorrhage: an exploratory analysis. World Neurosurg. 2016;96:215–21. https://doi.org/10.1016/j.wneu.2016.04.002.
Scharbert G, Wetzel L, Schrottmaier WC, Kral JB, Weber T, Assinger A. Comparison of patient intake of ticagrelor, prasugrel, or clopidogrel on restoring platelet function by donor platelets. Transfusion. 2015;55(6):1320–6. https://doi.org/10.1111/trf.12977.
Sehba FA, Mostafa G, Friedrich V Jr, Bederson JB. Acute microvascular platelet aggregation after subarachnoid hemorrhage. J Neurosurg. 2005;102(6):1094–100. https://doi.org/10.3171/jns.2005.102.6.1094.
Spoendlin J, Gagne JJ, Lewey JJ, Patorno E, Schneeweiss S, Desai RJ. Comparative effectiveness and safety of antiplatelet drugs in patients with diabetes mellitus and acute coronary syndrome. Pharmacoepidemiol Drug Saf. 2018. https://doi.org/10.1002/pds.4668.
Teng R. Ticagrelor: pharmacokinetic, pharmacodynamic and pharmacogenetic profile: an update. Clin Pharmacokinet. 2015;54(11):1125–38. https://doi.org/10.1007/s40262-015-0290-2.
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Pérez, M.A., Hellstern, V., Klötzsch, C., Bäzner, H., Henkes, H. (2019). Paraophthalmic Internal Carotid Artery Aneurysm: Incidental Paraophthalmic Aneurysm of the Right Internal Carotid Artery, Treated with Intra- and Extrasaccular Flow Diversion; Hyperresponse on Antiplatelet Medication with Sulcal Subarachnoid Hemorrhage; Reduction of the Antiplatelet Medication Dosage; Thromboembolic Occlusion of the p64 Flow Diverter Only 24 h After the Last Intake of Ticagrelor; Thrombectomy with Recanalization of the p64 and Good Clinical Outcome. In: Henkes, H., Lylyk, P., Ganslandt, O. (eds) The Aneurysm Casebook. Springer, Cham. https://doi.org/10.1007/978-3-319-70267-4_91-1
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