SNIS Updates Guidelines on Use of Antiplatelet and Antithrombotic Therapy in Neurointerventional Procedures

June 26, 2023—In an update to guidelines from 2014 published in Journal of NeuroInterventional Surgery, Schirmer et al and the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee outline a revised and advanced set of recommendations for the use of antiplatelet and antithrombotic therapy in neurointerventional procedures. These updated guidelines aim to educate practitioners on the treatment of specific pathologies and patients with specific comorbidities.

The guidelines were written via a consensus conference among the authors and supported with additional input from the SNIS Standards and Guidelines Committee and the SNIS Board of Directors.

All recommendations were formed from the data collected after a robust literature review of all research published since the previous guidelines were published in 2014 (December 2013-September 2022). According to the authors, the literature consisted of a mix of case studies and nonrandomized, single-center studies.

The first two recommendations help address platelet testing and when it is appropriate to resume anticoagulation and guide practice decisions. The remainder of the recommendations then address disease-specific considerations or comorbidities. The areas described include ruptured and unruptured brain aneurysms and patient comorbidities such as venous thrombosis, atrial fibrillation, brain arteriovenous malformations, intracranial atherosclerotic disease, elective and emergent carotid artery stenting, and cerebral venous thrombosis (Table 1).

In addition to providing recommendations, the authors also used this update to convey important distinctions on how the use of direct oral anticoagulants (DOACs) impacts neurointerventional procedures. It was explained that the use of DOACs, such as dabigatran, apixaban, betrixaban, edoxaban, and rivaroxaban, had significantly increased since the previous guidelines were released. As such, the authors offered an explanation on how these agents can be reversed in both urgent and emergent settings when necessary. In a brief overview, the authors discuss the approach for reversal of two categories of DOACs: direct thrombin inhibitors and direct factor Xa inhibitors.

The authors conclude that while there is a lower quality of evidence than compared with coronary interventions, the management of antiplatelets and antithrombotics for neurointerventional procedures is similar. However, additional prospective and randomized studies are needed to further strengthen these recommendations.