Comparison between prasugrel and clopidogrel used as antiplatelet medication for endovascular treatment of unruptured intracranial aneurysms. A meta-analysis

Abstract

Background Clopidogrel is routinely used to decrease ischemic complications during neurointerventional procedures. However, the efficacy may be limited by the antiplatelet resistance. Purpose To analyze the efficacy of prasugrel (PS) compared to clopidogrel (CP) in the cerebrovascular field. Data sources A systematic search of two large databases was performed for studies published from 2000 to 2018. Study selection According to PRISMA guidelines, we included studies reporting treatment-related outcomes of patients undergoing neurointerventional procedures under PS, and studies comparing PS and CP. Data analysis Random-effects meta-analysis was used to pool the following: overall rate of complications, ischemic and hemorrhagic events, influence of the dose of PS. Data synthesis Including 7 studies, 682 and 672 unruptured intracranial aneurysms were treated under PS (cases) and CP (controls), respectively. Low-dose (20 mg/5 mg) (loading and maintenance doses) of PS compared with the standard dose of CP (300 mg/75 mg) showed a significant reduction of the complication rate (OR = 0.36, 95% CI = 0.17–74, P = 0.006, I2 = 0%). Overall, ischemic complication rate was significantly higher among the CP group (40/672 = 6%, 95% CI = 3%–13%, I2 = 83% vs 16/682 = 2%, 95% CI = 1%–5%, I2 = 73%, P = 0.03). Low and high loading doses of PS 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%) of intra-periprocedural hemorrhages, respectively (P = 0.001), whereas low and high maintenance doses of PS were associated with 0% (0/433) and 0.9% (2/249, 95% CI = 0.3%–2%, I2 = 0%) of delayed hemorrhagic events, respectively (P = 0.001). Limitations Retrospective series and heterogeneous endovascular treatments. Conclusions In our study, low-dose of prasugrel, compared with clopidogrel premedication, is associated with an effective reduction of the ischemic events with an acceptable rate of hemorrhagic complications.