Assessing DOAC Impact Using a Point-of-Care Device in Neuroendovascular Procedures

Introduction Neuroendovascular procedures often require direct oral anticoagulants (DOACs) alongside dual antiplatelet therapy (DAPT). While platelet activity can be assessed, measuring DOAC anticoagulation effect, up until now, has not been available. Knowing DOAC effect may be crucial to patient outcomes. Methods Two patients received overlapping flow diverters (FD) for fusiform basilar artery (BA) aneurysms causing brainstem compression. DAPT and dabigatran administered perioperatively and at discharge. Platelet activity was monitored, and a new DOAC‐sensitive point‐of‐care device, was used to measure clotting time [Perosphere ClotChek (Perosphere, Danbury, CT, USA)]. Results Patient 1 (Figure 1): FD successfully implanted, discharged on day 3. Readmitted in <24 hrs. with diplopia and dizziness. New brainstem ischemia diagnosed, exhibiting right internuclear ophthalmoplegia, dissociated left eye nystagmus, and mild dysarthria. FD was occluded, and recanalized by mechanical thrombectomy. Forty‐eight hrs. post‐procedure, MRI showed progressive ischemic changes, consistent with locked in syndrome. Patient expired after palliative care.Patient 2 (Figure 2): FD successfully implanted, developed pontine ischemic lesion on day 5, possibly due to perforator branch insufficiency despite patent FD. After 14 hospital days, patient 2 was transferred to a rehabilitation facility.Clotting Time on readmission measured inadequate dabigatran effect in patient 1 after 3+ days of therapy (194s vs expected >290s); Patient 2 was properly anticoagulated (382s). In both patients, platelet function was inhibited. Conclusion Poor individual response to dabigatran in patient 1 likely contributed to fulminant FD and aneurysm sac thrombosis; rare in the early postoperative period, whereas in patient 2, imaging showed patent FD and partially thrombosed aneurysm sac, as expected. Aneurysm reconstruction with ten overlapping FD coupled with hypotension may have contributed to reduced perforating branch blood flow and subsequent brainstem ischemia.Given the spectrum of individual DOAC response, incorporating ClotChek in complex neuroendovascular procedures to measure DOAC effect, can ensure optimal anticoagulation and potentially better outcomes.