J Neurocrit Care.  2023 Jun;16(1):34-38. 10.18700/jnc.230016.

Ticagrelor washout bridged with GPIIb/IIIa inhibitor infusion to facilitate surgical care following placement of pipeline flow diverters: a case report

• Zweig A
• Stanley JS
• Patel R
• Agola J
• Halstead MR

• KMID: 2543390
• DOI: http://doi.org/10.18700/jnc.230016

Abstract

Background
Pipeline flow diverters (PFDs) are becoming increasingly common. Antiplatelet medication is required to minimize periprocedural ischemic events. Short-acting GPIIb/IIIa inhibitors are frequently administered intraprocedurally; however, the role of these agents in postprocedural PFD management in the neurocritical care unit (NCCU) has been overlooked.
Case Report
A patient with an unruptured internal carotid artery aneurysm presented for PFD placement. PFD placement was complicated by post-procedure intra-PFD thrombosis and hemispheric ischemia. Aspirin and ticagrelor were restarted, and the surgery department consulted for tracheostomy and percutaneous endoscopic gastrostomy-tube placement. Short-half-life GPIIb/IIIa infusions served as bridges to surgery after aspirin and tirofiban washout.
Conclusion
NCCU management of complications of PFD placement remains under-researched. The use of long-acting antiplatelet agents post-PFD limits the safe administration of surgical procedures. Bridging with GPIIb/IIIa infusion may facilitate the safe delivery of intensive care in these cases.

Keyword

Case report; Neurocritical care unit; Pipeline flow diverter; Internal carotid artery aneurysm; Short-half-life antiplatelet

Figure

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  Fig. 1. Digital subtraction angiography performed on the second day of admission. Images were captured by interventional radiologist utilizing digital subtraction angiography. (A) Image demonstrates thrombus present in the internal carotid artery with downstream circulation blocked. (B) Image demonstrates revascularization after successful removal of thrombus via thrombectomy.

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  Fig. 2. Head computed tomography imaging captured on the third day of admission. Decompressive right hemicraniectomy evident. Continued subfalcine herniation also demonstrated.

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  Fig. 3. Day post-pipeline flow diverters (PFD) placement vs. patient’s theoretical platelet activity. PEG, percutaneous endoscopic gastrostomy.

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