Utility of Antiplatelet Therapy With Ticlopidine in Patients Refractory to Clopidogrel for Intracranial Stenting: A Single Institution Experience

Background: The use of antiplatelets in intra-arterial stenting for cerebrovascular disease has been associated with a decrease in morbidity and mortality. Ticlopidine, a thienopyridine that inhibits ADP-mediated platelet aggregation, has been used with aspirin to treat patients with stroke and prevent thromboembolic occlusion in patients who have undergone endovascular procedures. Because of the reported side effects associated with ticlopidine such as bleeding, thrombocytopenic thrombotic purpura and neutropenia, another thienopyridine, clopidogrel, became the agent of choice as an antiplatelet regimen. However, as the literature accumulates, it is becoming evident that many patients are resistant or allergic to clopidogrel, thus highlighting the need for an alternative antiplatelet agent to prevent complications associated with endovascular management. Methods: After IRB approval, our patient database was retrospectively screened for patients who underwent a cerebral stent placement in which ticlopidine and aspirin was substituted for clopidogrel and aspirin. These patients were followed for signs and symptoms of cerebrovascular disease and complications of ticlopidine treatment. Results: From 2009 to 2011, seven patients were identified to be clopidogrel resistant and no patients identified as allergic. Resistance was defined as less than 15% platelet inhibition on the VerifyNow ® P2Y12 assay (Accumetrics Inc., San Diego, CA). Neither complications of cerebrovascular disease nor those associated with ticlopidine treatment were identified. Conclusions: Ticlopidine and aspirin may be an appropriate treatment alternative in patients who are resistant to clopidogrel and aspirin undergoing cerebral stenting. doi: http://dx.doi.org/10.4021/jnr142w