Sterotactic Brain Biposy and Dual Antiplatelet Therapy

Question 1

State some possible consequences to continuing dual antiplatelet therapy during the perioperative period for a Stereotactic Brain Biopsy

Answer 1

Significant Extracranial Bleeding
Intraparenchymal Haemorrhage with limited ability to access the source and hence control it
Haematoma development with mass effect causing specific neurological deficits or raised ICP

Question 2

What might be the consequences of prematurely stopping dual antiplatelet therapy (DAPT) in a patient who was taking DAPT following the insertion of a drug eluting coronary artery stent 6 months previously

Answer 2

Risk of Stent Thrombosis
Risk of MI or ischaemia as a consequence of preexisting coronary artery disease
Rebound increase in tendance to thrombosis following the cessation of an ADP receptor antagonist

Question 3

What patient factors would increase the risk of an ischaemic event following premature cessation of Dual Antiplatelet therapy in a patient who had a drug eluting coronary artery stent inserted 6 months previously

Answer 3

Cigarette smoking
Diabetes Mellitus
Congestive heart failure with Left Ventricular Ejection Fraction <30%
Having Had PCI prior to the PCI they received to insert the drug eluting stent (i.e. more than once)
Previous MI
MI was the indication for the PCI in which the drug eluting stent was inserted

Question 4

What approaches might mitigate the risk to a patient in which the decision to stop Dual antiplatelet therapy is made to facilitate a stereotactic brain biopsy

Answer 4

Perform the brain biopsy in a centre with an on site 24 hours interventional cardiology support to attempt to mitigate the severity of any thrombosis that might occur

Consider bridging with a short acting GP IIb/IIIa inhibitor (e.g. abciximab, eptifibatide, and tirofiban) starting within 24 hours of stopping the ABP receptor blockade (i.e. stopping the clopidogrel or ticagrelor)

Consider bridging with a short acting reversible P2Y12 receptor antagonist such as Cangrelor

Consider continuing aspirin only in the perioperative period if there is high risk of stent thrombosis and the neurosurgeon deems the biopsy a low risk for bleeding

Question 5

What specific contradictions are there to performing a stereotactic brain biopsy under sedation?

Answer 5

Patient unable to comply with instruction e.g. learning disability, dementia, poor hearing
Patient refusal
Patient movement disorder
Patient inability to lie still or lie flat
Chronic Cough
Significant Sleep Aponea
Difficult Airway
Patient anxiety or claustrophobia

Question 6

What specific complications are there to performing a stereotactic brain biopsy under sedation

Answer 6

Loss of airway and difficulties with access due to the use of a frame
Patient obtundation and therefore a rise in PaCO2 and decrease in PaO2 which may cause increase in intracranial pressure and potential implications for the biopsy
Patient movement making biopsy not feasible or causing complications
Patient pain due to inadequate topicalisation of the scalp or inadequate analgesia
Risk of nausea and vomiting due to for example stress or analgesia