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Strbian D, Tsivgoulis G, Ospel J, Räty S, Cimflova P, Georgiopoulos G, Ullberg T, Arquizan C, Gralla J, Zelenak K, Hussain S, Fiehler J, Michel P, Turc G, van Zwam WH. European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion. J Neurointerv Surg 2024; 16:e7. [PMID: 39043395 PMCID: PMC11347260 DOI: 10.1136/jnis-2024-022053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 06/11/2024] [Indexed: 07/25/2024]
Abstract
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
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Affiliation(s)
- Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Johanna Ospel
- Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Silja Räty
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Petra Cimflova
- Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Patras, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malmö, Sweden
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, INSERM U1266, Montpellier, France
| | - Jan Gralla
- Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | | | - Patrik Michel
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Bâtiment Hospitalier Principal, Lausanne, Switzerland
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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Strbian D, Tsivgoulis G, Ospel J, Räty S, Cimflova P, Georgiopoulos G, Ullberg T, Arquizan C, Gralla J, Zeleňák K, Hussain S, Fiehler J, Michel P, Turc G, Van Zwam W. European stroke organisation and European society for minimally invasive neurological therapy guideline on acute management of basilar artery occlusion. Eur Stroke J 2024:23969873241257223. [PMID: 38752743 DOI: 10.1177/23969873241257223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
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Affiliation(s)
- Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Johanna Ospel
- Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Silja Räty
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Petra Cimflova
- Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malmö, Malmö, Sweden
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, INSERM U1266, Montpellier, France
| | - Jan Gralla
- Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | | | - Patrik Michel
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Bâtiment Hospitalier Principal, Lausanne, Switzerland
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | - Wim Van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Lu WZ, Lin HA, Hou SK, Bai CH, Lin SF. Efficacy and safety of tirofiban in patients with acute ischemic stroke treated with endovascular thrombectomy: A frequentist and Bayesian meta-analysis. Vascul Pharmacol 2023; 153:107244. [PMID: 37992511 DOI: 10.1016/j.vph.2023.107244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/10/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Tirofiban is an antiplatelet treatment approved for acute coronary syndrome, but it has not been rigorously evaluated for efficacy and safety in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). METHODS Electronic databases were systematically searched for studies conducted from January 1, 2015, to July 31, 2021, that evaluated tirofiban administration for patients with AIS treated with EVT in comparison with control. Risk ratios (RRs) and confidence intervals (CIs) were estimated for favorable functional outcomes (FFOs), mortality, and symptomatic intracranial hemorrhage (SICH), each 90 days after AIS. Bayesian hierarchical modeling was performed to obtain posterior RR and its 95% highest posterior density (HPD) for validation. RESULTS Compared with controls, tirofiban users exhibited increased FFOs (RR, 1.18; 95% CI, 1.08-1.30), decreased mortality (RR, 0.77; 95% CI, 0.64-0.92), and no difference in SICH (RR, 0.97; 95% CI, 0.77-1.23). Tirofiban users in the postbolus infusion subgroup exhibited increased FFOs (RR, 1.20; 95% CI, 1.07-1.35), decreased mortality (RR, 0.71; 95% CI, 0.58-0.88), and no increase in SICH (RR, 0.97; 95% CI, 0.72-1.29). The bolus-only subgroup showed no differences in FFO, mortality, or SICH between the tirofiban and control groups. Consistent results were obtained for posterior density of FFO (posterior RR, 1.20; 95% HPD, 1.06-1.34), mortality (posterior RR, 0.77; 95% HPD, 0.63-0.92), and SICH (posterior RR, 0.98; 95% HPD, 0.71-1.26). CONCLUSION For patients with AIS treated with EVT, tirofiban improved FFOs, decreased mortality, and did not increase SICH compared with controls; postbolus infusion for administering tirofiban was more favored than the bolus-only regimen.
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Affiliation(s)
- Wei-Zhen Lu
- Department of Emergency Medicine, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
| | - Hui-An Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sen-Kuang Hou
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sheng-Feng Lin
- Department of Emergency Medicine, Taipei Medical University Hospital, Taipei, Taiwan; School of Public Health, College of Public Health, Taipei Medical University, Taipei, Taiwan; Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Liu C, Yang X, Liu M, Wang J, Li G. Systematic review and meta-analysis of the efficacy and safety of adjunctive use of tirofiban in patients treated with endovascular therapy for acute ischemic stroke at different embolic sites. Medicine (Baltimore) 2023; 102:e35091. [PMID: 37800797 PMCID: PMC10553052 DOI: 10.1097/md.0000000000035091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/15/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND The use of tirofiban as an adjunct to endovascular therapy (EVT) for acute ischemic stroke has been controversial. We aimed to assess the differences in safety and efficacy of EVT adjuvant to tirofiban in patients with anterior circulation stroke (ACS) and posterior circulation stroke (PCS). METHODS We systematically searched Pubmed, Embase, Cochrane Library, and Web of Science. Cohort studies and randomized controlled trials that compared treatment with tirofiban combined with EVT and EVT alone were included in our meta-analysis. The safety outcomes were symptomatic intracranial hemorrhage, and 3-month mortality. The efficacy outcomes were good functional outcome, excellent functional outcome, and successful recanalization (mTICI ≥ 2b). We performed subgroup analyses of anterior and posterior circulation strokes. RESULTS We included 15 studies with 4608 patients. For safety outcomes, tirofiban significantly reduced 3-month mortality in the ACS subgroup (odd ratio [OR] = 0.80, 95% confidence interval [CI] = 0.65-0.98, P = .03) without increasing the rate of symptomatic intracranial hemorrhage (OR = 1.12, 95% CI = 0.88-1.44, P = .35). In the PCS subgroup, tirofiban significantly reduced 3-month mortality (OR = 0.63, 95% CI = 0.50-0.80, P = .0001) and symptomatic intracranial hemorrhage (OR = 0.60, 95% CI = 0.37-0.95, P = .03). For efficacy outcomes, in the ACS subgroup, tirofiban significantly improved good functional outcome (OR = 1.24, 95% CI = 1.06-1.45, P = .008) but did not improve recanalization (OR = 1.17, 95% CI = 0.93-1.47, P = .17) and excellent functional outcome (OR = 1.19, 95% CI = 0.97-1.46, P = .10). In the PCS subgroup, tirofiban significantly improved recanalization rate (OR = 1.94, 95% CI = 1.43-2.65, P < .0001) and did not improve good functional outcome (OR = 1.03, 95% CI = 0.81-1.30, P = .81) and excellent functional outcome (OR = 0.84, 95% CI = 0.58-1.20, P = .34). CONCLUSION In acute ischemic stroke patients undergoing EVT, tirofiban improves good functional outcomes in ACS patients and increases recanalization rates in PCS patients on the 1 hand, reduces mortality, and does not increase the risk of symptomatic intracranial hemorrhage on the other. Tirofiban is safe and effective in both anterior circulation stroke and posterior circulation stroke patients undergoing EVT. More large multicentre randomized controlled studies are needed in the future.
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Affiliation(s)
- Chenxi Liu
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xun Yang
- Department of Neurology, Hechuan District People’s Hospital, Chongqing, China
| | - Mingsu Liu
- Department of Neurology, Zhongshan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jinping Wang
- Department of Neurology, Chongqing University Central Hospital, Chongqing, China
| | - Guangqing Li
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Räty S, Nguyen TN, Nagel S, Puetz V, Alemseged F, Abdalkader M, Schonewille WJ, Strbian D. What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke? Semin Neurol 2023; 43:345-355. [PMID: 37595603 DOI: 10.1055/s-0043-1771210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Liu C, Yang X, Liu M, Wang J, Li G. Meta-analysis of the efficacy and safety of tirofiban in patients with acute ischaemic stroke undergoing mechanical thrombectomy. Clin Neurol Neurosurg 2023; 228:107702. [PMID: 37058772 DOI: 10.1016/j.clineuro.2023.107702] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/18/2023] [Accepted: 03/26/2023] [Indexed: 03/30/2023]
Abstract
INTRODUCTION Mechanical thrombectomy is now widely used in acute ischaemic stroke, but its adjunctive antiplatelet aggregation regimen is controversial. This study aimed to investigate the safety and efficacy of tirofiban in patients with acute ischaemic stroke (AIS) who underwent mechanical thrombectomy. METHODS We systematically searched Pubmed, Embase, Cochrane Library, and Web of science. Randomized controlled studies and cohort studies comparing the tirofiban group and non-tirofiban group (control group) in patients with AIS who underwent mechanical thrombectomy. The primary safety outcomes were symptomatic intracranial hemorrhage (sICH), 3-month mortality, and re-occlusion rate. The primary efficacy outcomes were good functional outcome (mRS 0-2), excellent functional outcome (mRS 0-1), and successful recanalization (mTICI≥2b). RESULTS We included 22 studies with a total of 6062 patients. For safety outcomes, the tirofiban group had a non-significantly higher rate of sICH (OR = 0.90, 95 % CI = 0.73-1.10, P = 0.29) and a significantly lower rate of re-occlusion (OR = 0.40, 95 % CI = 0.19-0.82, P = 0.01) and 3-month mortality (OR = 0.71, 95 % CI = 0.61-0.82, P < 0.00001) compared to the control group. In terms of efficacy outcomes, significant improvement in good functional outcomes (mRS 0-2) (OR = 1.24, 95 % CI = 1.11-1.39, P = 0.0002) and recanalization rate (OR = 1.38, 95% CI = 1.17-1.62, P = 0.0001) compared to tirofiban, but not significant improvement in excellent functional outcomes(OR = 1.14, 95 % CI = 0.93-1.39, P = 0.21). In addition, compared with cardiogenic stroke, the large atherosclerotic stroke had a higher rate of good functional outcome (OR = 1.58, 95 % CI = 1.18-2.11, P = 0.002) and a lower rate of 3-month mortality (OR = 0.58, 95 % CI = 0.39-0.85, P = 0.005). Subgroup analysis by route of administration showed a significant improvement in good functional outcome in the intravenous group (OR = 1.27, 95 % CI = 1.08-1.50, P = 0.004), while no significant difference was found between the arterial and arteriovenous groups. CONCLUSION Treatment with tirofiban in patients with AIS with mechanical thrombectomy is effective in improving functional prognosis, arterial recanalization rates, and reducing 3-month mortality and re-occlusion rates, particularly in patients with large atherosclerotic stroke, without increasing the rate of symptomatic intracranial hemorrhage. Intravenous administration of tirofiban significantly improves the clinical prognosis compared to arterial administration. Tirofiban is effective and safe in patients with AIS.
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Affiliation(s)
- Chenxi Liu
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Xun Yang
- Department of Neurology, Hechuan District People's Hospital, Chongqing 401500,China.
| | - Mingsu Liu
- Department of Neurology, Zhongshan Hospital Affiliated to Fudan University, Shanghai 200032, China.
| | - Jinping Wang
- Department of Neurology, Chongqing University Central Hospital, 400050, China.
| | - Guangqing Li
- Department of Neurology, The Frist Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Ouyang M, Shajahan S, Liu X, Sun L, Carcel C, Harris K, Anderson CS, Woodward M, Wang X. Sex differences in the utilization and outcomes of endovascular treatment after acute ischemic stroke: A systematic review and meta-analysis. Front Glob Womens Health 2023; 3:1032592. [PMID: 36741299 PMCID: PMC9889638 DOI: 10.3389/fgwh.2022.1032592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/22/2022] [Indexed: 01/20/2023] Open
Abstract
Background Studies of sex differences in the use and outcomes of endovascular treatment (EVT) for acute ischemic stroke report inconsistent results. Methods We systematically searched PubMed and Embase databases for studies examining sex-specific utilization of EVT for acute ischemic stroke published before 31 December 2021. Estimates were compared by study type: randomized clinical trials (RCTs) and non-RCTs (hospital-based, registry-based or administrative data). Random effects odds ratios (ORs) were generated to quantify sex differences in EVT use. To estimate sex differences in functional outcome on the modified Rankin scale after EVT, the female:male ratio of ORs and 95% confidence intervals (CIs) were obtained from ordinal or binary analysis. Results 6,396 studies were identified through database searching, of which 594 qualified for a full review. A total of 51 studies (36 non-RCT and 15 RCTs) reporting on sex-specific utilization of EVT were included, and of those 10 estimated the sex differences of EVT on functional outcomes. EVT use was similar in women and men both in non-RCTs (OR: 1.03, 95% CI: 0.96-1.11) and RCTs (1.02, 95% CI: 0.89-1.16), with consistent results across years of publication and regions of study, except that in Europe EVT treatment was higher in women than men (1.15, 95% CI: 1.13-1.16). No sex differences were found in the functional outcome by either ordinal and binary analyses (ORs 0.95, 95% CI: 0.68-1.32] and 0.90, 95% CI: 0.65-1.25, respectively). Conclusions No sex differences in EVT utilization or on functional outcomes were evident after acute ischemic stroke from large-vessel occlusion. Further research may be required to examine sex differences in long-term outcomes, social domains, and quality of life. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=226100, identifier: CRD42021226100.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Sultana Shajahan
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Xiaoying Liu
- Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Lingli Sun
- Stroke Division, TheGeorge Institute for Global Health, Beijing, China
| | - Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Katie Harris
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Craig S. Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, NSW, Australia
| | - Mark Woodward
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,The George Institute for Global Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Xia Wang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia,Correspondence: Xia Wang
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Dong S, Li Y, Guo J, Luo Y, Fang J, Tang L, He L. Endovascular Treatment Combined With Standard Medical Treatment Improves Outcomes of Posterior Circulation Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:694418. [PMID: 35518202 PMCID: PMC9062408 DOI: 10.3389/fneur.2022.694418] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 03/15/2022] [Indexed: 02/05/2023] Open
Abstract
Aims Whether endovascular treatment (EVT) can further improve the prognosis of patients with posterior circulation ischemic stroke (PCIS) is unclear. This meta-analysis aims to compare the efficacy and safety of PCIS patients treated with EVT plus standard medical treatment (SMT) and SMT alone. Methods We systematically searched for relevant randomized controlled trials (RCTs) and prospective cohort trials in MEDLINE, EMBASE, and the Cochrane Library up to February 2022. The primary outcome was favorable functional outcome of the modified Rankin Scale (mRS) with scores of 0-2 or 0-3; secondary outcomes included successful recanalization rate, intracranial hemorrhage (ICH), or symptomatic intracranial hemorrhage (sICH) after treatment and 90-day mortality. Results We identified six studies including 1, 385 PCIS patients (957 with EVT plus SMT; 428 with SMT alone). EVT plus SMT substantially improved 90-day functional outcomes compared with SMT alone [mRS score of 0-2: RR=1.95, 95% CI (1.52 - 2.51), P < 0.001; mRS score of 0-3: RR = 1.85, 95% CI (1.49 - 2.30), P < 0.001, respectively]. Moreover, compared with SMT, combined treatment significantly improved the rate of successful recanalization [RR = 5.03, 95% CI (3.96-6.40), P < 0.001] and reduced 90-day mortality [RR = 0.71, 95% CI (0.63-0.79), P < 0.001] despite a higher risk of ICH [RR = 6.13, 95% CI (2.50-15.02), P < 0.001] and sICH [RR = 10.47, 95% CI [2.79-39.32), P = 0.001]. Conclusion Low-to-moderate evidence from RCTs and non-RCTs showed that increased ICH and sICH risk of EVT plus SMT did not translate to a higher risk of unfavorable outcomes compared with SMT and could even promote independence at 90 days in a real-world cohort.
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Affiliation(s)
- Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yanbo Li
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yaxi Luo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Tang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
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9
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Nso N, Nassar M, Trimingham M, Mbome Y, Lyonga Ngonge A, Badejoko SO, Akbar S, Azhar A, Lakhdar S, Ghallab M, Guzman Perez LM, Rizzo V, Munira MS. Invasive Management of Vertebrobasilar Artery Stenosis and Occlusion: A Meta-Analysis on Efficacy and Safety Endpoints. Cureus 2022; 14:e24751. [PMID: 35686282 PMCID: PMC9170364 DOI: 10.7759/cureus.24751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/05/2022] Open
Abstract
Vertebrobasilar angioplasty and stenting or mechanical thrombectomy (MT) using a stent retriever or suction thrombectomy are effective interventions in managing acute ischemic stroke caused by vertebrobasilar artery occlusion (VBAO). This study aims to investigate the safety and efficacy of self-expanding stents and balloon angioplasty in managing ischemic stroke. We reviewed the literature for relevant clinical trials and included those reporting the following primary outcomes: successful recanalization, favorable clinical outcome, and stenosis degree change. We included 24 studies (858 patients). In the subgroup analysis, participants were divided into three main subgroups based on the type of intervention: mechanical thrombectomy (MT), percutaneous transluminal angioplasty and stenting (PTAS), and MT+PTAS. Regarding overall mortality, the incidence was 34.5%, 9.9%, and 28.9% in the MT, PTAS, and MT+PTAS groups, respectively. The incidence of arterial dissection was 3.6% in the MT group, 3.1% in the PTAS group, and 16.7% in the MT+PTAS group. Incidence of distal embolization, MT, PTAS, and MT+PTAS groups had 3.4%, 5.8%, and 9.5% incidence rates, respectively. Favorable clinical outcomes were reported in 42.8% of subjects in the MT+PTAS group, 64.7% in the PTAS group, and 39.2% in the MT group. The incidence of intracranial hemorrhage was 5.2%, 4.5%, and 15.3% in the MT, PTAS, MT + PTAS groups, respectively. The incidence of successful recanalization was 85.3% in the MT group, 99.4% in the PTAS group, and 92.7% in the MT+PTAS group. Our analysis concludes that PTAS is the most effective intervention for VBAO and is associated with a lower rate of mortality compared to mechanical thrombectomy alone.
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Affiliation(s)
- Nso Nso
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
| | - Mahmoud Nassar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
| | - Mia Trimingham
- Internal Medicine, American University of Antigua, College of Medicine, New York, USA
| | - Yolanda Mbome
- Internal Medicine, Richmond University Medical Center, New York, USA
| | - Anthony Lyonga Ngonge
- Department of Medicine, The State University of New York (SUNY) Upstate University Medical Center, New York, USA
| | | | - Shahzad Akbar
- Internal Medicine, Kettering Medical Center, Dayton, USA
| | - Atika Azhar
- Internal Medicine, Upstate University Hospital, Syracuse, USA
| | - Sofia Lakhdar
- Medicine, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
| | - Muhammad Ghallab
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
| | - Laura M Guzman Perez
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
| | - Vincent Rizzo
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
| | - Most Sirajum Munira
- Internal Medicine/Cardiology, Weill Cornell Medicine, New York, USA
- Cardiology, Icahn School of Medicine at Mount Sinai, New York City (NYC) Health and Hospitals/Queens, New York, USA
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10
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Zhang A, Wu N, Liu X, Jiang T. Continuous intravenous tirofiban can improve the 90-day functional outcome and decrease 90-day mortality without increasing bleeding risk in acute ischemic stroke patients treated by endovascular therapy: A meta-analysis. J Clin Neurosci 2022; 99:109-116. [PMID: 35278931 DOI: 10.1016/j.jocn.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND The role of continuous intravenous administration of tirofiban in endovascular therapy is still unclear. This meta-analysis aims to evaluate the 90-day functional prognosis in acute ischemic stroke patients (AIS) treated by endovascular treatment and intravenous administration of tirofiban. METHODS We searched PubMed, Embase, and CENTRAL databases with the subject terms "tirofiban", "brain ischemia", and some related free words. Inclusion criteria were: (1) cohort study or randomized control trials; (2) AIS patients who received endovascular therapy; (3) the intervention or exposure was intravenous tirofiban monotherapy or combined with intra-arterial tirofiban; (4) containing data on modified Rankin Scale at 90 days and including at least one of the following indicators: mortality, symptomatic intracranial hemorrhage (sICH), intracranial hemorrhage (ICH), and recanalization. A summary odds ratio was calculated. RESULTS Twelve eligible studies, consisting of 3268 AIS participants, were identified. There was a significant trend of favorable outcomes (measured by mRS at three months) in the tirofiban group (ORs = 1.36; 95% CI = 1.09-1.70). In addition, compared with the non-tirofiban group, intravenous tirofiban was significantly associated with decreased risk of 90-day mortality (ORs = 0.73; 95% CI:0.59-0.89) and increased recanalization rate (ORs = 1.50; 95% CI:1.08-2.09) but no significant difference in rates of sICH (ORs = 0.93; 95% CI = 0.70-1.24) or ICH (ORs = 0.84; 95% CI = 0.62-1.15). CONCLUSIONS Intravenous tirofiban appears to be safe and effective when used following intra-arterial tirofiban or as monotherapy in AIS patients treated by endovascular therapy, which can improve the 90-day functional outcome, decrease the 90-day mortality and increase the possibility of early recanalization without increasing rates of sICH and ICH.
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Affiliation(s)
- Aiwu Zhang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Nihong Wu
- Department of Neurology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Xintong Liu
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Tao Jiang
- Department of Neurology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China.
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11
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Jiang C, Liu J, Zhang J, Cui Y, Yang J, Hao F, Fan Y, Wei J. Endovascular therapy for acute basilar artery occlusion caused by vertebral artery dissection: Case report. Medicine (Baltimore) 2021; 100:e27995. [PMID: 34964795 PMCID: PMC8615330 DOI: 10.1097/md.0000000000027995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 11/11/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE The best endovascular therapy revascularization strategies for acute ischemic stroke caused by vertebral artery dissection (VAD) are unclear. We describes a case of basilar artery (BA) occlusion caused by extracranial VAD, in which we used a stent-retriever to achieve thrombectomy in the BA through the contralateral vertebral artery (VA). PATIENT CONCERNS A 32-year-old male presented with a sudden-onset headache accompanied by articulation disorder, left-sided weakness, and tinnitus in the left ear. DIAGNOSIS Digital subtraction angiography showed the V1 to V2 segment dissection of the left VA and occlusion of the BA. INTERVENTIONS Thrombectomy was performed through the thinner right VA with three passes of the Solitaire FR device 4 × 20 mm in the BA, and angiograms showed modified treatment in cerebral ischemia 3 reperfusion of BA and left VA V4 segment still occluded. OUTCOMES The patient had a modified Rankin Scale of 2 at 90 days, and re-established blood flow of the left VA and BA. LESSONS When extracranial VAD complicated with BA occlusion, choosing the clean-road path to perform a BA thrombectomy may be a fast and effective treatment strategy.
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Affiliation(s)
- Changchun Jiang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
- Neurointerventional medical center of Inner Mongolia Medical University, Inner Mongolia, China
| | - Jiahui Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
- Neurointerventional medical center of Inner Mongolia Medical University, Inner Mongolia, China
| | - Jinfeng Zhang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
- Neurointerventional medical center of Inner Mongolia Medical University, Inner Mongolia, China
| | - Yujuan Cui
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Junfeng Yang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
- Neurointerventional medical center of Inner Mongolia Medical University, Inner Mongolia, China
| | - Fei Hao
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
- Neurointerventional medical center of Inner Mongolia Medical University, Inner Mongolia, China
| | - Yu Fan
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
- Neurointerventional medical center of Inner Mongolia Medical University, Inner Mongolia, China
| | - Jianqi Wei
- Graduate School of Inner Mongolia Medical University, Inner Mongolia, China
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12
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Ramgren B, Frid P, Norrving B, Wassélius J, Ullberg T. Endovascular therapy in basilar artery occlusion in Sweden 2016-2019-a nationwide, prospective registry study. Neuroradiology 2021; 64:959-968. [PMID: 34716767 PMCID: PMC9005406 DOI: 10.1007/s00234-021-02843-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
Purpose We present the first nationwide study on endovascular therapy for basilar artery occlusion (BAO) from early hospital management to 3-month outcome. Methods Data were collected on all acute ischaemic stroke patients registered 2016–2019 in the two national quality registers for stroke care and endovascular therapy (EVT), receiving EVT for BAO and subclassified into proximal, middle and distal. Results In all, 251 patients were included: 69 proximal, 73 middle and 109 distal BAO. Patients with proximal BAO were younger (66, middle 71, distal 76, p < 0.0001), less often female (27.5%, middle 47.9%, distal 47.7%, p = 0.015), more often smokers (28.6%, middle 20.3%, distal 11.5%, p < 0.0001), and fewer had atrial fibrillation (13.2%, middle 24.7%, distal 48.6%, p < 0.0001). Level of consciousness and NIHSS score did not differ by BAO subtype and 52.2% were alert on admission. Time from groin puncture to revascularization was significantly longer in patients with proximal BAO (71, middle 46, distal 42 min, p < 0.0001), and angioplasty and/or stenting was more often performed in patients with proximal (43.4%) and middle (27.4%) than distal (6.4%) BAO (p < 0.0001). Cumulative 90-day mortality was 38.6% (proximal 50.7%, middle 32.9%, distal 34.9%, p = 0.02). Older and pre-stroke dependent patients had higher mortality, as did patients in whom angioplasty/stenting was performed. Conclusion We confirm a serious outcome in BAO despite endovascular therapies, and demonstrate important differences relating to occlusion location in baseline characteristics, procedural time, therapeutic measures and outcome. Further in-depth analyses of factors affecting outcome in BAO are warranted. Supplementary Information The online version contains supplementary material available at 10.1007/s00234-021-02843-3.
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Affiliation(s)
- Birgitta Ramgren
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden. .,Section of Neuroradiology and Odontology, Center for Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden.
| | - Petrea Frid
- Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Neurology, Skåne University Hospital, Lund/Malmö, Sweden
| | - Bo Norrving
- Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Neurology, Skåne University Hospital, Lund/Malmö, Sweden
| | - Johan Wassélius
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Section of Neuroradiology and Odontology, Center for Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden
| | - Teresa Ullberg
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Section of Neuroradiology and Odontology, Center for Medical Imaging and Physiology, Skåne University Hospital, 221 85, Lund, Sweden.,Neurology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Neurology, Skåne University Hospital, Lund/Malmö, Sweden
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13
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Liu JC, Gao BL, Li HW, Chen FW, Shi HS, Wang Z, Wang ZL, Li TX. Effects of and prognostic factors affecting endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion. J Clin Neurosci 2021; 93:221-226. [PMID: 34656251 DOI: 10.1016/j.jocn.2021.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/30/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the clinical outcome and factors affecting the prognosis of endovascular mechanical thrombectomy of acute vertebrobasilar artery occlusion. MATERIALS AND METHODS Eighty-three patients with acute vertebrobasilar artery occlusion were treated with endovascular mechanical thrombectomy, and the recanalization rate, clinical outcomes at three months, modified DWI-PC-ASPECTS, and MRA-BATMAN scores were analyzed. RESULTS Following acute mechanical thrombectomy, the TICI 2B-3 score was achieved in all patients (100%). At three-month evaluation, 56 (67.5%) patients had good prognosis with the mRS score of 0-2, including 13 (23.2%) patients who had arterial occlusion caused by emboli and 43 (76.8%) who had atherosclerotic stenosis. In analyzing factors affecting the prognosis, a significant difference (P < 0.05) existed between patients with good (mRS 0-2) and poor (mRS 3-6) prognosis in the NIHSS (17.3 vs. 31.2, P = 0.000001), modified DWI-PC-ASPECTS (10.4 vs. 7.8, P = 0.021), and MRA-BATMAN (6.3 vs. 4.6, P = 0.003) scores. Univariate Logistic regression analysis demonstrated NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 to be the risk factors for poor prognosis. Multivariate Logistic regression analysis revealed NIHSS score ≥ 21 as an independent risk factor for poor prognosis. CONCLUSION Endovascular mechanical thrombectomy is safe and effective in recanalizing occluded vertebrobasilar artery occlusion, and NIHS score ≥ 21, modified DWI-PC-ASPECTS score ≤ 8.5, and MRA-BATMAN score ≤ 6.5 are the risk factors for poor prognosis.
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Affiliation(s)
- Jin-Chao Liu
- Department of Intervention, Henan Puyang Oilfield General Hospital, Puyang, Henan Province 457000, China
| | - Bu-Lang Gao
- Stroke Center, Henan Provincial People's Hospital, Henan University, Zhengzhou, Henan Province 450000, China
| | - Hong-Wei Li
- Department of Intervention, Henan Puyang Oilfield General Hospital, Puyang, Henan Province 457000, China
| | - Fu-Wen Chen
- Department of Intervention, Henan Puyang Oilfield General Hospital, Puyang, Henan Province 457000, China
| | - Hong-Sheng Shi
- Department of Intervention, Henan Puyang Oilfield General Hospital, Puyang, Henan Province 457000, China
| | - Zhan Wang
- Department of Intervention, Henan Puyang Oilfield General Hospital, Puyang, Henan Province 457000, China
| | - Zi-Liang Wang
- Stroke Center, Henan Provincial People's Hospital, Henan University, Zhengzhou, Henan Province 450000, China.
| | - Tian-Xiao Li
- Stroke Center, Henan Provincial People's Hospital, Henan University, Zhengzhou, Henan Province 450000, China
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14
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Tao C, Zhu Y, Zhang C, Song J, Liu T, Yuan X, Luo W, Chen C, Liu D, Zhu Y, Liu J, Hu W. Association between tirofiban monotherapy and efficacy and safety in acute ischemic stroke. BMC Neurol 2021; 21:237. [PMID: 34167477 PMCID: PMC8223269 DOI: 10.1186/s12883-021-02268-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/04/2021] [Indexed: 01/11/2023] Open
Abstract
Background Studies have suggested that glycoprotein IIb/IIIa antagonists such as tirofiban are beneficial for patients with acute coronary syndromes. However, it is still uncertain about the efficacy and safety of tirofiban in patients with acute ischemic stroke (AIS). Methods In this prospective non-randomized study, 255 AIS patients were recruited from 4 comprehensive stroke centers in China between January, 2017 and May, 2018. Among them,169 patients were treated with aspirin plus clopidogrel and 86 patients were treated with tirofiban. The primary functional outcome was the distribution of the 90 days’ modified Rankin Scale (mRS). The safety outcomes included the incidence of intracranial hemorrhage (ICH) at discharge and mortality at 3 months. Results In the propensity score matched cohort, tirofiban alone was noninferior to the dual antiplatelet with regard to the primary outcome (adjusted common odds ratio, 0.97; 95% confidence interval, 0.46 to 2.04; P = 0.93). Mortality at 90 days was 10% in the dual antiplatelet group and 8% in the tirofiban group (adjusted odds ratio 0.75; 95% CI 0.08 to 7.40, p = 0.81). There was no difference of the ICH rate between two groups (adjusted odds ratio 0.44; 95% CI 0.13 to 1.48, p = 0.18). In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar differences were found for functional and safety outcomes. Conclusions Our study suggested that tirofiban use appears to be safe as monotherapy in AIS treatment compared with common dual antiplatelet therapy, however, no improvement in functional outcomes was found. Trial registration Chinese clinical trial registry, ChiCTR2000034443, 05/07/2020. Retrospectively registered.
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Affiliation(s)
- Chunrong Tao
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Yuyou Zhu
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Chao Zhang
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Jianlong Song
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Tianlong Liu
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Xiaodong Yuan
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China
| | - Wenwu Luo
- Department of Pathology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Changchun Chen
- Department of Neurology, The Second People's Hospital of Anhui Province, Hefei, Anhui, China
| | - Dezhi Liu
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of TCM, 528 Zhang-Heng Road,Pu-Dong New Area, Shanghai, 201203, China
| | - Yuanyuan Zhu
- People's Hospital of LiXin County, BoZhou City, 236700, AnHui Province, China
| | - Jie Liu
- People's Hospital of LiXin County, BoZhou City, 236700, AnHui Province, China.
| | - Wei Hu
- Stroke Center & Department of Neurology, Division of Life Sciences and Medicine, the First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, Anhui, China.
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15
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Guo Y, Zhao K, Guo X, Yang M. Antiplatelet therapy and outcomes following endovascular therapy for acute ischemic stroke: A systemic review and meta-analysis. J Clin Neurosci 2021; 90:332-344. [PMID: 34275572 DOI: 10.1016/j.jocn.2021.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/31/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The outcomes of antiplatelet therapy (APT) in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT) remains controversial. Thus, we sought to make a systematic review and meta-analysis of recent clinical trials to confirm the safety and efficacy of APT. METHODS All of clinical trails were systematically retrieved from PubMed, Embase and Cochrane. The endpoints or main outcome measures included symptomatic intracranial hemorrhage (sICH), 3-month mortality, successful recanalisation (SR) and 3-month functional independence (FI). Odd ratios (ORs) with their 95% confidence intervals (CIs) were calculated to synthesize effect size by using random-effects models. Sensitivity analysis was performed via calculation of rest data owiting one by one. RESULTS 23 articles were included after screening. APT as an adjunct to EVT was associated with a higher likelihood of pooled successful recanalisation (OR 1.46, 95% CI 1.07-2.00) and 3-month FI (OR 1.24, 95% CI 1.01-1.51), no associated with sICH and 3-month mortality. However, Sensitivity analysis indicated that the association between APT and SR and 3-month FI were unstable. For patients with prior use of APT or receiving intravenous thrombolysis before EVT, no associated were found between APT and all of endpoints above. CONCLUSION Although adjuvant APT appears to increase the number of SR and 3-month FI, the results were unstable. Randomised controlled trials are needed to confirm the efficacy.
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Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, Qinghai 810016, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, Qinghai 810016, China
| | - Xinmei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, Yunnan 650504, China
| | - Mingfei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai 810007, China.
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16
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Duan H, Chen L, Shen S, Zhang Y, Li C, Yi Z, Wang Y, Zhang J, Li L. Staged Endovascular Treatment for Symptomatic Occlusion Originating From the Intracranial Vertebral Arteries in the Early Non-acute Stage. Front Neurol 2021; 12:673367. [PMID: 34220682 PMCID: PMC8245001 DOI: 10.3389/fneur.2021.673367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The ideal treatment for patients who survive from acute vertebrobasilar artery occlusion but develop aggressive ischemic events despite maximal medical therapy in the early non-acute stage is unknown. This paper reports the technical feasibility and outcome of staged endovascular treatment in a series of such patients with symptomatic intracranial vertebral artery occlusion. Methods: Ten consecutive patients who presented with aggressive ischemic events in the early non-acute stage of intracranial vertebral artery occlusion from Jan 2015 to Nov 2020 were retrospectively reviewed. Among them, eight male and two female patients with a mean age of 66.7 years developed aggressive ischemic events, and the NIHSS score was elevated by a median of 7 points despite medical therapy. All patients received staged endovascular treatment 4–21 days from onset, at an average of 11 days. The strategy of staged treatment was as follows: first, a microwire was passed through the portion of the occlusion, which was then dilated with balloon inflation to maintain the perfusion above TICI grade 2b. Then, with the use of antiplatelet drugs, the residual intravascular thrombus was gradually eliminated by the continuous perfusion and an activated fibrinolytic system, leaving the residual stenosis. A second stage of angioplasty with stent implantation was subsequently performed if residual stenosis was ≥50%. The NIHSS scores and mRS scores were compared between pre- and post-endovascular treatment groups and in the follow-up period. Results: Technical success was achieved in 9 patients who received staged endovascular treatment (perforation occurred in one patient during the first stage). The NIHSS scores were significantly improved, with a median score 7 points lower on discharge compared with the scores for the most severe status. Favorable outcomes with mRS score ≤ 2 were achieved in 7 and 9 patients at the 3-month follow-up and the latest follow-up, respectively, which was better than the preoperative status. Conclusion: Staged endovascular treatment might be a safe, efficient, and viable option in carefully selected patients with symptomatic intracranial vertebral artery occlusion in the early non-acute stage. However, this needs to be confirmed by further investigation, preferably in a large, controlled setting.
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Affiliation(s)
- Hongzhou Duan
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Li Chen
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shengli Shen
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Yang Zhang
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Chunwei Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Zhiqiang Yi
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Yingjin Wang
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Jiayong Zhang
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Liang Li
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
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Findler M, Turjman AS, Raymond J, White PM, Sadeh-Gonik U, Taschner CA, Mazighi M, Biondi A, Gory B, Turjman F. Interobserver Agreement in Scoring Angiographic Results of Basilar Artery Occlusion Stroke Therapy. AJNR Am J Neuroradiol 2021; 42:1458-1463. [PMID: 34117020 DOI: 10.3174/ajnr.a7182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/09/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The modified TICI Infarction grading system is a metric currently used to evaluate angiographic results of thrombectomy for large-vessel occlusion in ischemic stroke. Originally designed for evaluating MCA territories, it is currently used for other vessel occlusions, including the posterior circulation. We postulate that the modified TICI use for the posterior circulation is not accurate due to the different vascular territories supplied by vertebrobasilar vasculature, making grading more complex. MATERIALS AND METHODS We collected angiographic results from 30 patients who presented with acute posterior circulation occlusions between 2015 and 2018 and underwent thrombectomy in our institution. Eight observers were asked to evaluate the TICI scores before and after thrombectomy. The multirater statistics were computed using Fleiss κ analysis. Further data were collected regarding the potential brain territories at risk and the existence of atherosclerotic disease in the basilar artery. RESULTS The overall agreement κ reached 0.277 (SD, 0.013), which suggests a "fair" agreement among the raters. On average, 45% of observers achieved a high accuracy in predicting brain areas at risk of ischemia. As for the existence of basilar atherosclerotic disease, a high agreement (defined as at least 5 of 6 observers) was seen in 20 of the 30 patients. CONCLUSIONS Despite TICI being ubiquitous in stroke diagnostics, the high variability of posterior circulation TICI scores calls into question its use in these strokes. Other methods should be developed to assess recanalization in the posterior circulation.
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Affiliation(s)
- M Findler
- Department of Neurology and Interventional Neuroradiology (M.F.), Rabin Medical Center, Petah Tikva, Israel
| | - A S Turjman
- Cognition Medical Corporation (Alexis S. Turjman), Boston, Massachusetts
| | - J Raymond
- Département de Radiologie, Radio-Oncologie et Médecine Nucléaire (J.R.), Université de Montréal, Montreal, Quebec, Canada
| | - P M White
- Department of Neuroradiology (P.M.W.), Royal Victoria Infirmary, Newcastle, UK
| | - U Sadeh-Gonik
- Department of Radiology and Interventional Neuroradiology (U.S.-G.), Tel Aviv Medical Center, Tel-Aviv, Israel
| | - C A Taschner
- Department of Neuroradiology (C.A.T.), University Medical Centre Freiburg, Freiburg, Germany
| | - M Mazighi
- Department of Interventional Neuroradiology (M.M.), Fondation Rothschild Hospital, Paris, France
| | - A Biondi
- Department of Neuroradiology and Endovascular Therapy (A.B.), Besancon University Hospital, Besancon, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology (B.G.), Centre Hospitalier Régional Universitaire Nancy, Nancy, France
| | - F Turjman
- Department of Interventional Neuroradiology (Francis Turjman), Hospices Civils de Lyon, Lyon,France
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18
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Chen VHE, Lee GKH, Tan CH, Leow AST, Tan YK, Goh C, Gopinathan A, Yang C, Chan BPL, Sharma VK, Tan BYQ, Yeo LLL. Intra-Arterial Adjunctive Medications for Acute Ischemic Stroke During Mechanical Thrombectomy: A Meta-Analysis. Stroke 2021; 52:1192-1202. [PMID: 33611941 DOI: 10.1161/strokeaha.120.031738] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke with large vessel occlusion, the role of intra-arterial adjunctive medications (IAMs), such as urokinase, tPA (tissue-type plasminogen activator), or glycoprotein IIb/IIIa inhibitors, during mechanical thrombectomy (MT) has not been clearly established. We aim to evaluate the efficacy and safety of concomitant or rescue IAM for acute ischemic stroke with large vessel occlusion patients undergoing MT. METHODS We searched Medline, Embase, and Cochrane Stroke Group Trials Register databases from inception until March 13, 2020. We analyzed all studies with patients diagnosed with acute ischemic stroke with large vessel occlusion in the anterior or posterior circulation that provided data for the two treatment arms, (1) MT+IAM and (2) MT only, and also reported on at least one of the following efficacy outcomes, recanalization and 90-day modified Rankin Scale, or safety outcomes, symptomatic intracranial hemorrhage and 90-day mortality. Data were collated in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Sixteen nonrandomized observational studies with a total of 4581 patients were analyzed. MT only was performed in 3233 (70.6%) patients, while 1348 (29.4%) patients were treated with both MT and IAM. As compared with patients treated with MT alone, patients treated with combination therapy (MT+IAM) had a higher likelihood of achieving good functional outcome (risk ratio, 1.13 [95% CI, 1.03-1.24]) and a lower risk of 90-day mortality (risk ratio, 0.82 [95% CI, 0.72-0.94]). There was no significant difference in successful recanalization (risk ratio, 1.02 [95% CI, 0.99-1.06]) and symptomatic intracranial hemorrhage between the two groups (risk ratio, 1.13 [95% CI, 0.87-1.46]). CONCLUSIONS In acute ischemic stroke with large vessel occlusion, the use of IAM together with MT may achieve better functional outcomes and lower mortality rates. Randomized controlled trials are warranted to establish the safety and efficacy of IAM as adjunctive treatment to MT.
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Affiliation(s)
- Vanessa H E Chen
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Grace K H Lee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Choon-Han Tan
- Department of Medicine, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore (C.-H.T.)
| | - Aloysius S T Leow
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Ying-Kiat Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging (A.G., C.Y.), National University Health System, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging (A.G., C.Y.), National University Health System, Singapore
| | - Bernard P L Chan
- Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
| | - Vijay K Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.).,Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.).,Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore (V.H.E.C., G.K.H.L., A.S.T.L., Y.-K.T., C.G., V.K.S., B.Y.Q.T., L.L.L.Y.).,Division of Neurology, Department of Medicine (B.P.L.C., V.K.S., B.Y.Q.T., L.L.L.Y.), National University Health System, Singapore
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19
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Zhao H, Feng Y, Rong X, Mao Y, Wang Z, Ling Y, Dong Q, Cao W. Sequential tirofiban infusions combined with endovascular treatment may improve outcomes in acute ischemic stroke - a meta-analysis. Aging (Albany NY) 2021; 13:5426-5441. [PMID: 33582658 PMCID: PMC7950282 DOI: 10.18632/aging.202473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/30/2020] [Indexed: 12/20/2022]
Abstract
In this meta-analysis, we explored whether tirofiban could safely improve outcomes when combined with endovascular therapy in acute ischemic stroke with large vessel occlusion. We searched the PubMed, EMBASE, Web of Science, and The Cochrane Library databases from January 2000 to October 2019 for relevant RCTs/non-RCTs. A total of 13 trials involving 2584 patients, of whom 893 (34.5%) received tirofiban, were ultimately included in the meta-analysis. The results suggested that tirofiban improved patient independence at 90 days (51.2% vs 42.4%; OR 1.26; p =0.02) without increasing the risk of symptomatic intracranial hemorrhage (OR 1.01; p =0.96) or mortality (OR 0.86; p =0.09). There was no association between the use of tirofiban and recanalization rate (OR 1.35; p =0.11). Subgroup analysis showed that a loading dose followed by maintenance doses, but not a single dose, of tirofiban increased favorable 90-day functional outcomes (OR 1.49; p =0.0008). Moreover, low maintenance doses may be more effective than high maintenance doses (OR 1.41; p =0.02). These results suggest that adjunctive tirofiban treatment administered as a loading dose followed by low-dose maintenance may improve functional outcomes of endovascular therapy in acute ischemic stroke.
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Affiliation(s)
- Hongchen Zhao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiwei Feng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoming Rong
- Department of Neurology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yiting Mao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zigao Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.,State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Wenjie Cao
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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20
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Tang L, Tang X, Yang Q. The Application of Tirofiban in the Endovascular Treatment of Acute Ischemic Stroke: A Meta-Analysis. Cerebrovasc Dis 2021; 50:121-131. [PMID: 33401276 DOI: 10.1159/000512601] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 10/21/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The purpose of this meta-analysis is to evaluate the safety and efficacy of tirofiban during endovascular treatment (EVT) for acute ischemic stroke (AIS) patients. METHODS We systematically searched PubMed, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) databases for randomized controlled trials and cohort studies (published before May 1, 2020; no language restrictions) comparing tirofiban administration to blank control during EVT in patients with AIS. Our primary end points were the 3-month functional outcome, recanalization rate, symptomatic intracerebral hemorrhage, and 3-month mortality. RESULTS The incidence of 3-month modified Rankin Scale (mRS) 0-2 score of the tirofiban group was higher than that of the control group (odds ratio [OR] = 1.27, 95% CI [1.09, 1.48], p = 0.002) with heterogeneity (I2 = 34%, p = 0.11). Data pooled from the 6 studies describing the details of retriever stent in EVT revealed that tirofiban was associated with higher incidence of 3-month mRS 0-2 score (OR = 1.48, 95% CI [1.11, 1.96], p = 0.007). The recanalization rate was higher in the tirofiban group compared to the control group (OR = 1.66, 95% CI [1.16, 2.39], p = 0.006). There were no statistically significant differences in the incidence of symptomatic intracranial hemorrhage (OR = 0.97, 95% CI [0.73, 1.31], p = 0.86) and intracranial hemorrhage (OR = 1.08, 95% CI [0.59, 1.97], p = 0.80) between tirofiban and non-tirofiban group. Besides, the tirofiban administration was associated with lower mortality (OR = 0.75, 95% CI [0.62, 0.91], p = 0.003). CONCLUSIONS The application of tirofiban in EVT of AIS may improve functional outcomes and reduce mortality at 3 months. Besides, tirofiban does not seem to increase the risk of symptomatic intracranial hemorrhage and intracranial hemorrhage, either in the anterior or posterior circulation stroke.
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Affiliation(s)
- Lisha Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiangqi Tang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China,
| | - Qianwen Yang
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
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21
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Xun K, Mo J, Ruan S, Dai J, Zhang W, Lv Y, Du N, Chen S, Shen Z, Wu Y. A Meta-Analysis of Prognostic Factors in Patients with Posterior Circulation Stroke after Mechanical Thrombectomy. Cerebrovasc Dis 2020; 50:185-199. [PMID: 33378751 DOI: 10.1159/000512609] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Posterior circulation stroke is characterized by poor prognosis because its optimal thrombolysis "time window" is always missed. After mechanical thrombectomy (MT), the recanalization rate of posterior circulation obstruction is significantly increased, but prognosis remains poor. To best manage patients, prognostic factors are needed to inform MT triaging after posterior circulation stroke. METHODS A systematic literature search was done for the period through April 2020. Studies included those with posterior circulation stroke cases that underwent MT. The primary outcome measure in this study was the modified Rankin Scale on day 90. RESULTS No outcome differences were found in gender, atrial fibrillation, smoking, and coronary artery disease (OR = 1.07, 95% CI: 0.90-1.28; OR = 1.02, 95% CI: 0.82-1.26; OR = 1.26, 95% CI: 0.94-1.68; and OR = 0.84, 95% CI: 0.58-1.22, respectively). Hypertension, diabetes mellitus, and previous stroke correlated with poorer prognosis (OR = 0.61, 95% CI: 0.48-0.77; OR = 0.60, 95% CI: 0.50-0.73; and OR = 0.74, 95% CI: 0.55-0.99, respectively). However, hyperlipidemia correlated with better prognosis (OR = 1.28, 95% CI: 1.04-1.58). CONCLUSION Our analysis indicates that hypertension, diabetes mellitus, or previous stroke correlate with poorer outcomes. Intriguingly, hyperlipidemia correlates with better prognosis. These factors may help inform triage decisions when considering MT for posterior circulation stroke patients. However, large, multicenter, randomized controlled trials are needed to validate these observations.
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Affiliation(s)
- Kai Xun
- Department of Emergency, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Jiahang Mo
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shunyi Ruan
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinyao Dai
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wenting Zhang
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuqi Lv
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Nannan Du
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Shengyue Chen
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zefeng Shen
- Department of General Surgery, School of Medicine, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Yuanxi Wu
- The Second Clinical Medicine School, Zhejiang Chinese Medical University, Hangzhou, China,
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22
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Sun Y, Guo ZN, Yan X, Wang M, Zhang P, Qin H, Wang Y, Zhu H, Yang Y. Safety and efficacy of tirofiban combined with endovascular therapy compared with endovascular therapy alone in acute ischemic stroke: a meta-analysis. Neuroradiology 2020; 63:17-25. [PMID: 32844236 DOI: 10.1007/s00234-020-02530-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 08/17/2020] [Indexed: 12/31/2022]
Abstract
Endovascular treatment (EVT) has been widely used for treating acute ischemic stroke (AIS). However, the safety and efficacy of treating AIS with tirofiban combined with EVT remain controversial. Therefore, we conducted a meta-analysis to evaluate this treatment. Randomized controlled trials and cohort studies that compared treatment with tirofiban combined with EVT and EVT alone were included in our meta-analysis. Those published from inception to March 31, 2020, were searched using the PubMed, Web of Science, Embase, and Cochrane Library databases. Safety was assessed based on symptomatic intracranial hemorrhage (sICH) incidence and 3-month mortality. Efficacy was assessed based on modified Rankin Scale (mRS) scores at 3 months post-EVT and recanalization rates. Data were analyzed using either the random-effects or fixed-effects model based on the heterogeneity of studies. In total, one RCT, six prospective studies, and four retrospective studies (2387 AIS cases) were assessed. Our meta-analysis showed that tirofiban combined with EVT did not increase sICH risk (RR, 1.06; 95%CI, 0.79 to 1.42; P = 0.72) and 3-month mortality (RR, 0.87; 95%CI, 0.74 to 1.04; P = 0.12). Recanalization rates were not significantly different between patients treated with tirofiban combined with EVT and those treated with EVT alone (RR, 1.04; 95%CI, 1.00 to 1.08; P = 0.07), but tirofiban combined with EVT was significantly associated with favorable functional outcomes (mRS score, 0-2) in AIS patients (RR, 1.13; 95%CI, 1.02 to 1.25; P = 0.02). Tirofiban combined with EVT appears to be safe and potentially effective in treating AIS.
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Affiliation(s)
- Yingying Sun
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Zhen-Ni Guo
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Xiuli Yan
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Meiqi Wang
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Peng Zhang
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Haiqiang Qin
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan Wang
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Hongjing Zhu
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China
| | - Yi Yang
- Neuroscience Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Xinmin Street, Chang Chun, Jilin, 130021, China.
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23
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Zhu X, Cao G. Safety of Glycoprotein IIb-IIIa Inhibitors Used in Stroke-Related Treatment: A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2020; 26:1076029620942594. [PMID: 32727211 PMCID: PMC7394033 DOI: 10.1177/1076029620942594] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background: Endovascular therapy and intravenous thrombolysis with recombinant tissue plasminogen activator are the 2 most recommended treatments for acute ischemic stroke (AIS). Glycoprotein (GP) IIb-IIIa inhibitors are short-acting selective reversible antiplatelet agents that emerged as promising therapeutic agents for AIS about 10 years ago. Given the unclear safety profile and application coverage of GP inhibitors, we conducted this meta-analysis to explore the same. Methods: We used GP IIb-IIIa inhibitors, intracranial hemorrhage, and mortality as the key words on Medline, Web of Science, and the Embase databases. Randomized controlled trials, prospective literatures, and retrospective studies in English published between 1990 and 2020 were screened. The outcomes were relative risk (RR) of death and 90-day intracerebral hemorrhage (ICH). We pooled the results in 2 categories and conducted a subgroup analysis stratified by different drugs. The choice of the effects model depended on the value of I2. Results: In all, 3700 patients from 20 studies were included. No GP IIb-IIIa inhibitors were found to have a remarkable influence on the ICH rate. The RR values of symptomatic ICH for abciximab and eptifibatide were 4.26 (1.89, 9.59) and 0.17 (0.04, 0.69), respectively. Both tirofiban and abciximab could decrease the mortality rate within 90 days. Age > 70 years, National Institutes of Health Stroke Scale > 15, and overall dose > 10 mg are risk factors for ICH events with tirofiban usage. Thrombectomy combined with tirofiban was safe for arterial reocclusion prevention. Conclusions: In stroke-related treatment, administration of GP IIb-IIIa inhibitors could be safe, but care should be taken regarding drug species and doses. Abciximab can increase the risk of symptomatic intracranial hemorrhage. Tirofiban and eptifibatide can be considered safe in low doses. Suitable patients should be selected using strict criteria.
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Affiliation(s)
- Xiaolin Zhu
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, People's Republic of China.,Both the authors contributed equally to this work
| | - Genmao Cao
- Department of Vascular Surgery, Second Hospital of Shanxi Medical University, Taiyuan, People's Republic of China.,Both the authors contributed equally to this work
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24
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Letter regarding "Endovascular treatment of acute intracranial vertebrobasilar artery occlusion: a multicenter retrospective observational study". Neuroradiology 2019; 62:135. [PMID: 31802157 DOI: 10.1007/s00234-019-02324-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
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