Use of Cangrelor and Platelet Reactivity Unit Monitoring in Patients With Acute Ischemic Stroke

Introduction: Cangrelor is a short-acting, intravenous P2Y12 receptor antagonist approved for use during percutaneous coronary intervention. Due to its rapid onset and offset, reversible platelet inhibition, and intravenous route of administration, cangrelor has gained traction as an off-label bridging antiplatelet agent in neurovascular patients with acute ischemic stroke, particularly those undergoing mechanical thrombectomy or with contraindications to oral therapy. However, limited data exist describing real-world usage, platelet inhibition assay monitoring, infusion rate adjustment, and safety outcomes. This study aimed to evaluate the use of cangrelor in patients with acute ischemic stroke, characterize the role of platelet reactivity unit (PRU) monitoring, and assess the incidence of bleeding and thrombotic complications.


Methods: This was a retrospective analysis that included adult patients admitted with acute ischemic stroke who received cangrelor between January 1, 2023, and December 31, 2024, at a large academic medical center. Patient demographics, cangrelor dosing, PRU assays, oral P2Y12 transition, 30-day ischemic stroke recurrence, and major bleeding events were evaluated. Major bleeding events were categorized by using ISTH definitions.


Results: A total of 41 patients were included, with the median cangrelor infusion duration of 46 hours (IQR 24-118). Initial median infusion rate was 2.0 mcg/kg/min (IQR 0.75-2.0). PRU assays were collected in 56% of infusions, with at least one level collected showing consistent platelet inhibition (median PRU 61, IQR 23-100). Major bleeding occurred in 15 (5%) patients, most commonly defined by hemoglobin decreases ≥2 g/dL. One infusion was discontinued due to bleeding. Ischemic stroke reoccurred in 2 patients (5%) at 30 days. Most patients, 36 (88%) were transitioned to oral P2Y12 inhibitors, clopidogrel or ticagrelor, with wide variability in loading strategies.


Conclusions: Cangrelor may be a safe alternative antiplatelet agent in patients who could not receive oral P2Y12 inhibitors in acute ischemic stroke. PRU assay monitoring could be considered.