F Cagnazzo1, P Perrini2, P-H Lefevre3, G Gascou3, C Dargazanli3, C Riquelme3, I Derraz3, D di Carlo2, A Bonafe3, V Costalat3. 1. From the Neuroradiology Department (F.C., P.-H.L., G.G., C.D., C.R., I.D., A.B., V.C.), University Hospital Güi de Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France f.cagnazzo86@gmail.com. 2. Department of Neurosurgery (P.P., D.d.C.), University of Pisa, Pisa, Italy. 3. From the Neuroradiology Department (F.C., P.-H.L., G.G., C.D., C.R., I.D., A.B., V.C.), University Hospital Güi de Chauliac, Centre Hospitalier Universitaire de Montpellier, Montpellier, France.
Abstract
BACKGROUND: Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by antiplatelet resistance. PURPOSE: Our aim was to analyze the efficacy of prasugrel compared with clopidogrel in the cerebrovascular field. DATA SOURCES: A systematic search of 2 large databases was performed for studies published from 2000 to 2018. STUDY SELECTION: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under prasugrel, and studies comparing prasugrel and clopidogrel. DATA ANALYSIS: Random-effects meta-analysis was used to pool the overall rate of complications, ischemic and hemorrhagic events, and influence of the dose of prasugrel. DATA SYNTHESIS: In the 7 included studies, 682 and 672 unruptured intracranial aneurysms were treated under prasugrel (cases) and clopidogrel (controls), respectively. Low-dose (20 mg/5 mg; loading and maintenance doses) prasugrel compared with the standard dose of clopidogrel (300 mg/75 mg) showed a significant reduction in the complication rate (OR = 0.36; 95% CI, 0.17-74, P = .006; I2 = 0%). Overall, the ischemic complication rate was significantly higher in the clopidogrel group (40/672 = 6%; 95% CI, 3%-13%; I2 = 83% versus 16/682 = 2%; 95% CI, 1%-5%; I2 = 73%; P = .03). Low and high loading doses of prasugrel were associated with 0.6% (5/535; 95% CI, 0.1%-1.6%; I2 = 0%) and 9.3% (13/147; 95% CI, 0.2%-18%; I2 = 60%) intraperiprocedural hemorrhages, respectively (P = .001), whereas low and high maintenance doses of prasugrel were associated with 0% (0/433) and 0.9% (2/249; 95% CI, 0.3%-2%; I2 = 0%) delayed hemorrhagic events, respectively (P = .001). LIMITATIONS: Retrospective series and heterogeneous endovascular treatments were limitations. CONCLUSIONS: In our study, low-dose prasugrel compared with clopidogrel premedication was associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.
BACKGROUND:Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by antiplatelet resistance. PURPOSE: Our aim was to analyze the efficacy of prasugrel compared with clopidogrel in the cerebrovascular field. DATA SOURCES: A systematic search of 2 large databases was performed for studies published from 2000 to 2018. STUDY SELECTION: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under prasugrel, and studies comparing prasugrel and clopidogrel. DATA ANALYSIS: Random-effects meta-analysis was used to pool the overall rate of complications, ischemic and hemorrhagic events, and influence of the dose of prasugrel. DATA SYNTHESIS: In the 7 included studies, 682 and 672 unruptured intracranial aneurysms were treated under prasugrel (cases) and clopidogrel (controls), respectively. Low-dose (20 mg/5 mg; loading and maintenance doses) prasugrel compared with the standard dose of clopidogrel (300 mg/75 mg) showed a significant reduction in the complication rate (OR = 0.36; 95% CI, 0.17-74, P = .006; I2 = 0%). Overall, the ischemic complication rate was significantly higher in the clopidogrel group (40/672 = 6%; 95% CI, 3%-13%; I2 = 83% versus 16/682 = 2%; 95% CI, 1%-5%; I2 = 73%; P = .03). Low and high loading doses of prasugrel were associated with 0.6% (5/535; 95% CI, 0.1%-1.6%; I2 = 0%) and 9.3% (13/147; 95% CI, 0.2%-18%; I2 = 60%) intraperiprocedural hemorrhages, respectively (P = .001), whereas low and high maintenance doses of prasugrel were associated with 0% (0/433) and 0.9% (2/249; 95% CI, 0.3%-2%; I2 = 0%) delayed hemorrhagic events, respectively (P = .001). LIMITATIONS: Retrospective series and heterogeneous endovascular treatments were limitations. CONCLUSIONS: In our study, low-dose prasugrel compared with clopidogrel premedication was associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.
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