Neurointervention.  2021 Nov;16(3):285-292. 10.5469/neuroint.2021.00290.

Treatment of In-Stent Stenosis Following Flow Diversion of Intracranial Aneurysms with Cilostazol and Clopidogrel

• Dowlati E
• Pasko KBD
• Liu J
• Miller CA
• Felbaum DR
• Sur S
• Chang JJ
• Liu AH
• Armonda RA
• Mai JC

• KMID: 2522044
• DOI: http://doi.org/10.5469/neuroint.2021.00290

Abstract

In-stent stenosis is a feared complication of flow diversion treatment for cerebral aneurysms. We present 2 cases of patients treated with pipeline flow diversion for unruptured cerebral aneurysms. Initial perioperative dual antiplatelet therapy (DAPT) consisted of standard aspirin plus clopidogrel. At 6-month follow-up cerebral angiography, the patients were noted to have developed significant in-stent stenosis (63% and 53%). The patients were treated with cilostazol and clopidogrel for at least 6 months. Subsequent angiography at 1-year post-treatment showed significant improvement of the in-stent stenosis from 63% to 34% and 53% to 21%. The role of cilostazol as treatment of intracranial in-stent stenosis has not been previously described. Cilostazol’s vasodilatory effect and suppression of vascular smooth muscle proliferation provides ideal benefits in this setting. Cilostazol plus clopidogrel may be a safe and effective alternative to standard DAPT for treatment of in-stent stenosis following flow diversion and warrants further consideration and investigation.

Keyword

Endovascular procedures; Intracranial aneurysm; Stents; Cilostazol; Clopidogrel; Aspirin.

Figure

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  Fig. 1. Timeline of diagnosis and treatment of patient cases. ICA, internal carotid artery; W0, discovery of aneurysm; W, week.

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  Fig. 2. Angiographic images for Case 1. (A) Left internal carotid artery (ICA) injection showing a left fusiform paraclinoid aneurysm measuring 8.5 mm by 10.8 mm. (B) Six-month follow-up cerebral angiogram with left ICA injection showing significant in-stent stenosis of up to 63% compared to immediate distal ICA diameter (white arrow). (C) Cerebral angiogram with left ICA injection at one-year follow-up from procedure and 6-month post cilostazol treatment demonstrating improved in-stent stenosis decreased to 34% (white arrow).

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  Fig. 3. Angiographic and imaging for Case 2. (A) Left ICA injection after Pipeline Embolization Device deployment showing normal ICA caliber without stenosis. (B) Six-month follow-up cerebral angiogram with left ICA injection showing significant in-stent stenosis of 53% compared to immediate proximal ICA diameter. (C) One-year follow-up angiogram from the procedure and 6-month post cilostazol treatment demonstrating improved instent stenosis decreased to 21%.

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