Patients who require interruption of dual antiplatelet therapy (DAPT) after intracranial or coronary artery stenting for invasive procedures are at an increased risk of stent thrombosis. Limited evidence exists for the use of cangrelor (an intravenous P2Y12 inhibitor) as a bridging agent in patients with intracranial stents

We describe a safe and effective protocol leveraging cangrelor as a bridging agent for an aneurysmal subarachnoid hemorrhage(SAH) patient (with both fresh intracranial and intracardiac stents) in need of an invasive procedure. 

A case report and review of the literature on PubMed was performed and summarized.

A 68 year old woman presented with chest pain and headache. She was found to have myocardial infarction and underwent percutaneous coronary intervention (PCI) with drug-eluting stent placement and initiated on aspirin and ticagrelor. Post PCI, CT brain revealed diffuse aneurysmal SAH from a ruptured anterior communicating artery aneurysm and underwent coil embolization with bilateral A1/A2 atlas neuroform stents. DAPT was continued with P2Y12 platelet reactivity unit (PRU) monitoring. Due to the need for a tracheostomy and ventriculoperitoneal shunt, ticagrelor was stopped and tirofiban was initiated for DAPT bridging. She developed tirofiban-related thrombocytopenia, requiring discontinuation. After platelet recovery (3 days), cangrelor was initiated as a bridge and titrated to a patient-specific PRU goal. Cangrelor was stopped 1 hour before and resumed 2 hours after surgery. Ticagrelor loading dose was administered 1 hour prior to discontinuation of cangrelor infusion. Aspirin was continued throughout the hospital course. No perioperative hemorrhagic complications were noted. Subsequent cerebral angiography confirmed intracranial stent patency.