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Título

Acute cerebral thrombosis caused by flow diversion stent and resistance to ticagrelor - Case report

RESUMO

Case presentation: A 52-year-old female presented to the interventional neurology team for treatment of saccular aneurysm located in the ophthalmic segment of the left internal carotid artery. As comorbidities she reported having Systemic Arterial Hypertension (SAH). She reported using losartan 50mg and two weeks before the procedure the neurologist prescribed prasugrel and acetylsalicylic acid 100mg. Cerebral angiography was requested for treatment of the aneurysm. In the cerebral angiography a flow diversion stent was positioned in the left middle cerebral artery. The final control showed incomplete opacification of the internal carotid due to platelet aggregation, denoting subsequent stenosis. Balloon angioplasty was performed, but was unsuccessful. It was necessary to use a hyperglide balloon, showing improvement of the left internal carotid artery, but presenting occlusion of the upper trunk of the left M1 associated with the avascular area. A Trevo stent progression was performed in the same catheter, released in the m3-m2 segment of the left middle cerebral, and thrombus was removed. Being requested Computed Tomography of the skull for follow-up.
Discussion: Taking into consideration that the patient in question takes the platelet antiaggregant ticagrelor 90 mg, it is necessary to point out some information about it. Ticagrelor is a platelet antiaggregant medication that acts differently from clopidogrel and prasugrel. The 3 drugs have the same mechanism of action, which is to inhibit the platelet receptor P2Y12, but while the thienopyridines act irreversibly, ticagrelor has a reversible effect (LI et al., 2022). Based on the case of the patient in question and according to a study published by the American Journal of Neuroradiology, several factors can influence intracranial aneurysm thrombosis, such as: flow-diverter stenting, which causes reduced blood flow. However, due to the lack of detailed measurements of intra-aneurysmal flow, its real impact remains uncertain (BRINA, 2019).
Final Comments: The reported case and exposed publications bring the discussion succession of infrequent events. The patient used prasugrel and acetylsalicylic acid within two weeks prior to the angiography and at the time of the procedure was administered ticagrelor. Conduct after placement of a flow diversion stent in the left middle cerebral artery caused cerebral thrombosis, which was resolved with thrombectomy and the use of tirofiban hydrochloride.

Palavras Chave

ticagrelor; stent; thrombosis;

Área

Neurologia Intervencionista